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http://www.archive.org/details/manualofpracticeOOstev 


A  MANUAL 


PRACTICE  OF  MEDICINE, 


PEEPARED 


ESPECIALLY  FOR  STUDENTS. 


BY 

A.  A.  STEVENS,  A.M.,  M.D., 

PROFESSOR  OF  PATHOLOGY  IN   THE  WOMAN'S  MEDICAL  COLLEGE  OF  PENNSYLVANIA  i 

LECTURER   ON   PHYSICAL    DIAGNOSIS    IN    THE    UNIVERSITY   OF  PENNSYLVANIA 

PHYSICIAN   TO  ST.   AGNES  HOSPITAL  AND  TO  THE  OUT-PATIEMT 

DEPARTMENT  OF  THE   EPISCOPAL  HOSPITAL,   ETC. 


"  is  an  arch  where  through 

Gleams  that  untravelled  world  whose  margin  fades 
Forever  and  forever  as  we  move." 


FIFTH  EDITION,  REVISED  AND  ENLARGED. 


ILLUSTRATED. 


PHILADELPHIA  : 
W.  B.  SAUNDERS   &  COMPANY, 

1901. 


Copyright,  1900, 
By  W.  B.  SAUNDERS   &   COMPAN"^ 


St4- 


PRESS    OF 
',V.    ?.    SAUNDERS     &.    COMPANY. 


PREFACE  TO  THE  FIFTH  EDITION. 


This  edition  has  been  tlioronghly  revised,  and  contains 
many  important  modifications  and  considerable  additions. 
The  chapter  on  Diseases  of  the  Pancreas,  the  introductory 
chapter  on  Diseases  of  the  Blood  and  of  the  Ductless  Glands, 
and  the  articles  on  Appendicitis,  Angina  Pectoris,  Aphasia, 
Myxoedema,  and  Syringo-myelia,  have  been  entirely  rewritten. 
New  articles  treating  of  Acute  Cholecystitis,  Tuberculosis  of 
the  Kidney,  Gastroptosis  and  Enteroptosis,  and  Chronic 
Cerebral  Leptomeningitis  have  been  introduced.  The  author 
ventures  to  hope  that  the  work  in  its  present  form  may  be 
found  equal  to  existing  requirements,  and  that  it  may  prove 
as  acceptable  to  students  of  medicine  as  former  editions. 

314  S.  Sixteenth  St.,  Philada., 
September,  1898. 


PREFACE  TO  THE  FIRST  EDITION. 


Pope  says,  "  Half  our  knowledge  we  must  snatch,  not 
take."  If  this  be  true  of  general  knowledge,  it  is  certainly 
true  of  the  knowledge  of  medicine  as  it  is  taught  in  the  schools 
of  to-day.  In  view  of  this  fact,  there  seems  to  be  a  real  need 
for  books  which  present  their  subjects  in  an  assimilable  form. 

At  tine  request  of  many  students  the  author  has  written  this 
book  with  the  hope  that  it  may  serve  as  an  outline  of  Practice 
of  Medicine,  which  shall  be  enlarged  upon  by  diligent  atten- 
dance upon  lectures  and  critical  observation  at  the  bedside. 

In  its  preparation  the  ^vritings  of  the  following  authors 
have  been  freely  consulted  :  Striimpell,  Osier,  Fagge,  Bristowe, 
Frerichs,  Liebermeister,  Vierordt,  Eichhorst,  Wood,  Ross, 
Gowers,  Sansom,  Henry,  Tyson,  Pepper,  Paul,  Murrell,  Starr, 
Hilton,  Duhring,  Stelwagon,  Van  Harlingen,  Tilbury  Fox, 
Hardaway,  Seller,  Cohen,  Browne,  Jacobi,  Bruce,  Brunton, 
Charcot,  Dujarden-Beaumetz,  Pavy,  Mitchell,  and  Trousseau. 


CONTENTS. 


Diseases  of  the  Digestive  System. 

General  Symptomatology —  page 

The  Teeth 17 

The  Tongue 17 

Fetor  of  the  Breath 18 

The  Appetite 19 

Dysphagia 19 

Vomiting,  or  Emesis 19 

The  Vomit 20 

Examination  of  the  Gastric  Contents 21 

Acidity  of  the  Gastric  Contents 24 

Rumination,  or  Merycismus 25 

Hiccough , "25 

Abdominal  Pain  and  Tenderness 25 

The  Stools 26 

Abdominal  Distention 27 

Diseases  of  the  Mouth,  Tonsils,  Pharynx,  and  (Esophagus — 

Stomatitis < 27 

Tonsillitis ■ 30 

Hypertrophy  of  the  Tonsils 32 

Pharyngitis 33 

vSpasm  of  the  Oesophagus 36 

Organic  Qilsophageal  Obstruction 36 

Diseases  of  the  Stomach — 

Acute  Gastritis ' 37 

Dyspepsia 38 

Atonic  Dyspepsia 39 

Nervous  Dyspepsia 39 

Catarrhal  Dyspepsia 41 

Gastralgia 43 

Gastric  Ulcer 45 

Gastric  Cancer 47 

Pyloric  Obstruction  and  Dilatation  of  the  Stomach 48 

Gastroptosis  and  Enteroptosis 49 

Hfematemesis 50 

Diseases  of  the  Intestines  and  Peritoneum — 

Constipation 51 

Intestinal  Colic 52 


VI  CONTENTS. 

Diseases  of  the  Intestines  and  Peritoneum  {Continued) —  page 

Diarrhoea 52 

Intestinal  Catarrh 53 

Acute  Entero-colitis 56 

Cholera  Infantum 57 

Dysentery 59 

Cholera  Morbus 62 

Appendicitis • 63 

Intestinal  Obstruction  ;  Ileus 65 

Animal  Parasitic  Affections 68 

Peritonitis 71 

Ascites • 73 

Diseases  of  the  Pancreas — 

Pancreatic  Hemorrhage 75 

Acute  Pancreatitis 75 

Chronic  Pancreatitis 76 

Canter  of  the  Pancreas 77 

Cysts  of  the  Pancreas 78 

Pancreatic  Calculi 78 

Diseases  of  the  Liver — 

Area  of  Liver  Dulness 79 

Palpation  of  the  Liver 79 

Percussion  of  the  Liver 80 

Jaundice,  or  Icterus     . ■    •    -, 80 

Icterus  Neonatorum ;    .  81 

■  Acholia 82 

Catarrhal  Jaundice 82 

Biliary  Calculi      83 

Acute  Inflammation  of  the  Gall-bladder 85 

Hypersemia  of  the  Liver 86 

Cirrhosis  of  the  Liver 87 

Abscess  of  the  Liver 90 

Cancer  of  the  Liver 91 

Amyloid  Liver 92 

Hydatid  Cysts  of  the  Liver '  .    .    .    .  93 

Acute  Yellow  Atrophy  of  the  Liver 94 

Diseases  of  the  Kidneys, 

General  Symptomatology — 

ThetJrine 95 

Polyuria 95 

Urea 95 

Lithuria 96 

Urates 97 

Leucin  and  Tyrosin      97 

Phosphates 98 

Chlorides 99 

Oxaluria 99 

Urobilinuria 100 

Glucosuria,  or  Glycosuria 100 


CONTENTS.  Vll 

General  Symptomatology  {Continued) —  page 

Albuminuria .  102 

Acetonuria 103 

Diaceturia  and  Oxybuturia 103 

Hsematuria .        .  103 

Hferaoglobinnria      104 

Indicanuria 104 

Bile 104 

Chyluria 104 

Pyuria 105 

Diseases  of  the  Kidneys,  and  Pelvis  of  the  Kidney — 

Renal  Hypersemia 105 

Uraemia .' 106 

Acute  Nephritis 107 

Chronic  Parenchymatous  Nephritis 109 

Chronic  Interstitial  Nephritis      110 

Amyloid  Kidne}'^    ......        112 

Renal  Calculus 113 

Pyelitis 115 

Hydronephrosis 116 

Floating  Kidney 117 

Tuberculosis  of  the  Kidney 118 


Diseases  of  the  Blood  and  the  Ductless  Glands. 

General  Symptomatology — 

Normal  Blood 119 

Examination  of  the  Blood 119 

Plethora    . 124 

Hydrsemia 124 

Anhydrsemia 124 

Melansemia , 125 

Polycythsemia 125 

Microcytosis  and  Macrocytosis 125 

Poikilocytosis 125 

Nucleated  Red  Cells 125 

Leukocytosis 126 

Leukoppenia 126 

Lipsemia 126 

Blood  Parasites 127 

Oligochromsemia 127 

Oligocythsemia 127 

Anemia,  Addison's  Disease,  Exophthalmic  Goitre,  and  Myxcedema — 

Anseraia 127 

Symptomatic  Anseraia 128 

Pernicious  An?emia 128 

Leukocythsemia 130 

Pseudo-leukaemia 131 

Chlorosis .  132 

Addison's  Disease 133 


VUl  CONTENTS. 

Anaemia,  Addison's  Disease,  Exophthalmic  Goitre,  and  Myxoedema 

{Continued} —  page 

Exophthalmic  Goitre 133 

Myxoedema 135 

Diseases  of  the  Cieculatory  System. 

General  Symptomatology — 

The  Apex-beat    .    ! 137 

Displacement  of  the  Apex-heat 138 

Changes  in  the  Force  and  Extent  of  the  Apex-beat 138 

Abnormal  Centres  of  Pulsation 139 

Jugular  Pulsation 140 

PraRCordial  Prominence 140 

Palpation 140 

Percussinn 140 

Auscultation 141 

The  Intensity  of  the  Heart-sounds 141 

Reduplication  of  the  Heart-sounds 142 

Adventitious  Sounds,  or  Murmurs 142 

Hsemic  Murmurs 142 

Pericardial  Friction-sounds 143 

The  Aneurismal  Murmur,  or  Bruit 143 

The  Pulse 143 

Palpitation 146 

Dropsy 147 

General  Cyanosis 147 

Diseases  of  the  Pericardium — 

Pericarditis 148 

Hydro-pericardium 150 

Hfemo-pericardium 151 

Pneumo-pericardium      152 

Diseases  of  the  Heart — 

Endocarditis 152 

Chronic  Valvular  Affections 153 

Aortic  Stenosis,  or  Aortic  Obstruction 153 

Aortic  Insufficiency,  or  Aortic  Regurgitation 154 

Mitral  Stenosis,  or  Mitral  Obstruction 154 

Mitral  Insufficiency,  or  Mitral  Regurgitation 155 

Tricuspid  Stenosis,  or  Tricuspid  Obstruction 156 

Tricuspid  Insufficiency,  or  Tricuspid  Regurgitation 156 

Pulmonary  Stenosis,  or  Pulmonary  Obstruction 156 

Pulmonary  Insufficiency,  (jr  Pulmonary  Regurgitation 156 

Acute  Ulcerative  Endocarditis •  159 

Acute  Myocarditis 160 

Fibroid  Heart 160 

Hypertrophy  of  the  Heart        161 

Dilatation  of  the  Heart 162 

Fatty  Infiltration  of  the  Heart 163 

Fatty  Degeneration  of  the  Heart 164 

Angina  Pectoris 165 


CONTENTS.  IX 

Diseases  of  the  Arteries —  page 

Aneurism  of  the  Aorta 166 

Thoracic  Aneurism 167 

Aneurism  of  the  Abdominal  Aorta 169 

Arterio-sclerosis 169 

Diseases  of  the  Eespiratory  System. 

General  Symptomatology — 

The  Eed  Nose 171 

Flattening  of  tlie  Bridge  of  the  Nose 171 

Movement  of  tlie  AIeb  Nasi  during  Respiration 171 

Nasal  Discharge 171 

The  Sense  of  Smell 171 

Epistaxis 172 

S[)asm  of  the  Laryngeal  Adductors 172 

Aphonia,  or  Loss  of  Voice 172 

Paralysis  of  tlie  Laryngeal  Muscles 173 

Dyspnoea 173 

Number  of  Respirations  per  Minute 174 

Cheyne-Stokes,  or  Tidal-wave  Breathing      174 

Cough 174 

Expectoration 175 

The  Microscopy  of  Sputum 176 

Inspection  of  the  Chest 179 

Phthisinoid  Chest 179 

Racliitic  Chest 179 

Emphysematous  Chest 179 

Local  Prominences  and  Depressions    . ISO 

Expansion 181 

Palpation 181 

Percussion 182 

Auscultation     .    .    .    . - 183 

Mensuration 187 

Diseases  of  the  Nose  and  Larynx — 

Coryza 188 

Chronic  Nasal  Catarrh .  189 

Acute  Catarrhal  Laryngitis 191 

Chronic  Laryngitis 192 

Spasmodic  Croup >    •    •        •    •  194 

Membranous  Croup 195 

Laryngismus  Stridulus 195 

(Edema  of  the  Larynx 196 

Diseases  of  the  Lungs — 

Bronchitis 197 

Dilatation  of  the  Bronchial  Tubes 203 

Asthma 205 

Hay  Asthma 208 

Pulmonary  Emphysema 209 

HEemopiysis 212 

Pulmonary  Apoplexy 213 


X  CONTENTS. 

Diseases  of  the  Lungs  {Continued) —  page 

C'ongestion  of  the  Lungs 214 

Croupous  Pneumonia 216 

Catarrhal  Pneumonia 221 

Chronic  Interstitial  Pneumonia 225 

Gangrene  of  the  Lung 226 

Abscess  of  the  Lung 227 

(Edema  of  the  Lungs ,    .  228 

Pulmonary  Collapse 229 

Pulmonary  Tuberculosis .        230 

Diseases  of  the  Pleura — 

Pleurisy 237 

Hycirothorax 241 

Pneumothorax 241 

Hsemothorax 243 

Pyothorax 243 


Acute  Infectious  Diseases. 

Fever 244 

Period  of  Incubation 247 

Date  at  which  Eashes  Appear 247 

Protection  from  Future  Attacks 248 

Periodic  Remissions,  or  Intermissions  in  the  Fever    ......  248 

Fevers  Associated  with  Jaundice 249 

Termination  by  Crisis 249 

Subnormal  Temperature 249 

Simple  Continued  Fever 250 

Typhoid  Fever 251 

Typhus  Fever 258 

Relapsing  Fever 260 

Cerebro-spinal  Fever .  261 

Malarial  Fever 264 

Scarlet  Fever 271 

Measles 274 

Rotheln •    •    .    .  276 

Smallpox 277 

Varicella  . ' 281 

Vaccinia 281 

Erysipelas 283 

Yellow  Fever 285 

Acute  General  Tuberculosis 287 

Diphtheria 288 

Wiiooping-cough             293 

Influenza 295 

Mumps ,    .     • 297 

Cholera •    .    .  298 

Tetanus 302 

Dengue 303 

Hydrophobia 304 


CONTENTS.                                     .  XI 

Constitutional  Diseases.  page 

Rheumatic  Fever 306 

Chronic  Articular  Rheumatism 310 

Other  Manifestations  of  Rheumatism 311 

Gout 313 

Rheumatoid  Arthritis 316 

Rickets 318 

Lithpemia 319 

Diabetes 321 

Diabetes  Insipidus 324 

Scurvy 32o 

Haemophilia 326 

Purpura  Haemorrhagica 327 

Diseases  of  the  Nervous  System. 
Disturbances  of  Motion, 

Paralysis .  328 

Irregular  Paralysis .  328 

Monoplegia  -    .    • .  329 

Hemiplegia 329 

Paraplegia 330 

Convulsions 331 

Epileptiform  Convulsions 331 

Tetanic  Convulsions 332 

Hysteroidal  Convulsions 332 

Local  Convulsions 333 

Saltatory  Spasm , 383 

Salaam  Convulsions 333 

Choreiform  Movements      333 

Athetosis 334 

Tremors 335 

The  Gait 335 

The  Reflexes    •    •    • 336 

Paradoxical  Contraction 338 

Disturbances  of  Sensation. 

AnEesthesia 338 

Hemiansesthesia 338 

Monanaesthesia 339 

Paranaesthesia 339 

Hyperaesthesia 339 

Paraesthesia 340 

Neuralgia 340 

Muscular  Sensibility 340 

Muscular  Sense 340 

Disturbances  of  Nutrition. 

Muscular  Atrophy 341 

Reaction  of  Degeneration 341 

Arthropathies 342 

Ulceration  Resulting  from  Perverted  Nutrition 343 


CONTENTS. 

Disturbances  of  Consciousness.  „.«■,, 

•'  PAGE 

Coma 343 

Trance 344 

Somnambulism 345 

Ecstasy 345 

Catalepsy 345 

Disturbances  of  the  Special  Senses. 

The  Eye 345 

The  Ear 346 

Psychical  Disturbances. 

Delusion 346 

Illusion 347 

Hallucination 347 

Imperative  Conception 347 

Morbid  Impulse 347 

Delirium 348 

Diseases  of  the  Brain,  Cord,  Nerves,  and  Muscles. 

Tuberculous  Meningitis 349 

Simple  Leptomeningitis 351 

Chronic  Leptomeningitis 351 

Chronic  Pachymeningitis 352 

Hemorrhagic  Pachymeningitis 352 

Hydrocephalus 353 

Paretic  Dementia 355 

Cerebral  Paralysis  of  Children 356 

Cerebral  Hyperemia 357 

Cerebral  Ansemia 358 

Cerebral  Hemorrhage 359 

Obstruction  of  the  Cerebral  Arteries 363 

Cerebral  Softening 365 

Morbid  Growths  in  the  Brain •   .  366 

Abscess  of  the  Brain , 369 

Cretinism 370 

Spinal  Leptomeningitis 371 

Chronic  Spinal  Pachymeningitis 372 

Acute  Myelitis 373 

Chronic  Myelitis 375 

Sclerosis  of  the  Spinal  Cord 376 

Locomotor  Ataxia 376 

Primary  Spastic  Paraplegia 379 

Amyotrophic  Lateral  Sclerosis 380 

Ataxic  Paraplegia 380 

Disseminated  Cerebro-spinal  Sclerosis 380 

Hereditary  Ataxia 381 

Syringo-myelia 382 

Acute  Anterior  Poliomyelitis 383 


CONTENTS.  Xlll 

PAGE 

Progressive  Muscular  Atrophy     = .  385 

Bulbar  Paralysis ■ 386 

Acute  Ascending  Paralysis 387 

Caisson  Disease -388 

Idiopathic  Muscular  Atrophy 388 

Pseudo-hypertrophic  Paralysis 389 

Neuralgia 390 

Migraine 393 

Headache 395 

Neuritis ,    .    .    . 399 

Multiple  Neuritis 401 

Sciatica : » 402 

Facial  Paralysis 403 

Epilepsy ■ 404 

Aphasia 407 

Vertigo      409 

Meniere's  Disease 410 

Hysteria , 411 

Neurasthenia 415 

Chorea  .    . 416 

Paralysis  Agitans 418 

Artisan's  Cramp ". 420 

Tetany .  420 

Thorasen's  Disease 421 

Kaynaud's  Disease 422 

Acute  A ngio-neurotic  (Edema 422 

Facial  Hemi-atrophy 423 

Acromegalia 423 

Sunstroke 424 

Intoxications- — 

Alcoholism 426 

Opium-poisoning 428 

Chronic  Lead-poisoning • 429 

Chronic  Mercurial  Poisoning 430 

Chronic  Arsenical  Poisoning 431 

Diseases  of  the  Skin  and  its  Appendages. 

General  Symptomatology — 

The  Color  of  the  Skin 432 

Hardness,  or  Induration  of  the  Skin 433 

Oedema,  or  Dropsy  of  the  Subcutaneous  Tissues 434 

Glossy  Skin 434 

Enlargement  of  the  Superficial  Veins        434 

Cutaneous  Emphysema 434 

Abnormal  Conditions  of  the  Nails 435 

Cutaneous  Eruptions— 

Macules 435 

Purpuric  Spots ,    - 436 

Vesicles 438 

Blebs,  or  Bullse .440 


XIV  CONTENTS. 

Cutaneous  Eruptions  {Continued) —  page 

Pustules 440 

Papules 442 

Tubercles 443 

Wheals,  or  Pomphi 444 

Crusts 444 

Scales 445 

Ulcers 446 

Diseases  of  the  Sweat-glands — 

Anidrosis 448 

Hyperidrosis 448 

Bromidrosis 449 

Chromidrosis 449 

Sudamen ■ 449 

Functional  Diseases  of  the  Sebaceous  Glands — 

Seborrhcea 450 

Comedo 451 

Milium 452 

Steatoma 453 

Inflammatory  Diseases  of  the  Skin — 

Erythema  Simplex 453 

Erythema  Intertrigo 454 

Erythema  Nodosum 454 

Erythema  Multiforme 454 

Urticaria 455 

Herpes  Simplex 456 

Herpes  Zoster 457 

Herpes  Iris 458 

Acne  Vulgaris 458 

Acne  Rosacea 460 

Furunculus 461 

Carbunculus 462 

Psoriasis 462 

Eczema 464 

Lichen  Ruber  and  Lichen  Planus 467 

Prurigo 488 

Dermatitis  Herpetiformis 468 

Dermatitis 469 

Ecthyma 471 

Pemphigus 472 

Impetigo 473 

Impetigo  Contagiosa 474 

Miliaria 475 

Atrophic  Affections  of  the  Skin — 

Albinism 476 

Vitiligo 476 

Atrophic  Affections  of  the  Hair  and  Nails 477 

Hypertrophic  Affections  of  the  Skin — 

Pompholix 481 

Lentigo 482 

Chloasma 482 


CONTENTS.  XV 

Hypertrophic  Affections  of  tlie  Skin  [Continued) —  page 

Keratosis  Pilaris 483 

Molluscum  Epitheliale 484 

Callositas 484 

Clavus 485 

Cornu  Cutaneum 486 

Verruca 4S6 

Nsevus 487 

Ichthyosis     •    •    •    •_ .•••■•. 487 

Hypertrophic  Affections  of  the  Hair  and  Nails 488 

Scleroderma ■ 488 

Morphoea 489 

Elephantiasis 489 

Dermatolysis 490 

New  Growths  of  the  Skin — 

Keloid 491 

Fibroma 491 

Angioma 492 

Xanthoma 492 

Lupus  Erythematosa  . 493 

Lupus  Vulgaris .  494 

Syphilis  Cutanea 496 

Leprosy 498 

Epithelioma 500 

Ainhum 501 

Neuroses  of  the  Skin — • 

Dermatalgia » 501 

Pruritus o 502 

Parasitic  Affections  of  the  Skin — 

Tinea  Tricophytina. ...*..,.  503 

Tinea  Versicolor 505 

Tinea  Favosa 506 

Scabies 506 

Pediculosis ' 507 


DISEASES 


DIGESTIVE  SYSTEM 


THE  TEETH  A^D  GUMS. 

Delayed  dentition,  and  the  eruption  of  badly-formed 
teeth,  often  residt  from  rickets  or  congenital  syphilis. 

Caries  of  the  teeth  results  from  many  conditions ;  notably, 
an  unnatural  softness  of  the  teeth,  lack  of  cleanliness,  dys- 
pepsia, the  use  of  certain  drugs,  and  diabetes. 

Hutchinson's  teeth. — The  lateral  incisors  of  the  upper  jaw 
are  pegged,  and  the  central  incisors  of  the  same  jaw  have 
convex  sides,  and  crescentic  notches  on  their  cutting  edges. 
These  peculiarities  indicate  hereditary  syphilis,  and  are  noted 
only  in  the  permanent  teeth. 

A  blue  line  on  the  gums  near  the  insertion  of  the  teeth 
usually  indicates  chronic  lead  poisoning.  Copper  and  silver 
poisoning  occasionally  produce  similar  lines. 

Spongy,  bleeding  gums  are  often  associated  with  scurvy. 
Swelling  of  the  gums  with  tenderness  and  salivation  is  indica- 
tive of  mercurial  poisoning  (ptyalism). 

THE  TONGUE. 

Fur  on  the  tongue. — This  consists  for  the  most  part  of  ac- 
cumulated epithelial  cells,  ])articles  of  food,  and  microorgan- 
isms, and  results  from  an  elevation  of  temperature  or  from 
disturbed  innervation. 
2 


18  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

A  light,  uniform  coat  is  often  noted  in  health,  particularly  in 
those  who  sleep  with  the  mouth  open.  Other  causal  condi- 
tions are : — 

(1)  Febrile  diseases. 

(2)  Dyspepsia. 

(3)  Catarrhal  conditions  of  the  nose  and  throat. 
Circumscribed  furring  often  indicates  lofal  disturbance,  as  a 

jagged  tooth  or  tonsillitis. 

Unilateral  furring  may  result  from  disturbed  iunervation,  as 
in  conditions  affecting  the  second  and  third  branches  of  the 
fifth  nerve.  It  has  been  noted  in  neuralgia  of  those  branches, 
and  in  fractures  of  the  skull  involving  the  foramen  rotundum. 
.  The  dry,  brown,  and  fissured  tongue  is  noted  in  low  fevers,  as 
typhoid  fever,  typhoid  pneumonia,  typhoid  dysentery. 

A  red,  beefy  tongue  is  noted  in  certain  febrile  diseases,  as 
typhoid  fever  and  scarlet  fever,  and  in  diabetes. 

The  ^' straivberry  tongue^'  is  characterized  by  a  white  fur, 
through  which  project  bright  red  and  prominent  papillae.  It 
is  seen  in  the  early  stage  of  scarlet  fever. 

A  gray-coated  and  flabby  tongue,  with  an  oval  bare  spot  in 
the  centre,  which  is  red  and  glossy,  is  sometimes  seen  in  chil- 
dren, and  is  indicative  of  gastro-intestinal  catarrh,  or  "mucous 
disease."     (Starr.) 

Tremor  of  tlie  Tongue. 

Trembling  of  the  tongue  is  noted  in  many  conditions ;  it  is 
peculiarly  marked  in  low  fevers  (typhoid),  in  alcoholism,  and 
in  paretic  dementia. 

Scars  on  the  Tongue. 

Scars  on  the  tongue  often  result  from  syphilitic  lesions,  or 
from  the  tooth  wounds  of  epilepsy. 

FETOR  OF  THE  BREATH. 

This  is  often  due  to  local  inflammation,  as  chronic  rhinitis, 
tonsillitis,  etc. ;  to  the  retention  of  decomposing  food,  to  caries 


VOMITING,   OR   EMESIS.  19 

of  the  teeth,  to  certain  lung  diseases,  especially  gangrene  and 
bronchiectasis,  to  dyspepsia,  and  to  the  ingestion  of  certain 
foods  or  drugs. 

THE  APPETITE. 

Boulimia,  or  inorclincUe  appetite,  is  a  common  symptom  in 
nervous  dyspepsia,  hysteria,  diabetes,  and  in  certain  insani- 
ties, notably  in  paretic  dementia.  It  may  be  due  to  intestinal 
parasites. 

Anoi^exia,  or  loss  of  appetite,  is  a  symptom  common  to  many 
conditions. 

Pica  is  a  craving  for  unnatural  articles  of  food,  and  is  noted 
particularly  in  chlorosis,  insanity,  and  pregnancy. 

DYSPHAGIA. 

Dysphagia,  or  difficult  swallowing,  may  result  from:  (1) 
Local  inflammations.  (2)  Stricture  of  the  oesophagus,  spas- 
modic or  organic.  (3)  Paralysis,  local,  as  in  diphtheritic 
paralysis ;  or  centric,  as  in  bulbar  disease. 

VOMITING,  OR  EMESIS. 

Etiology. — (1)  Toxic,  from  ptomaines,  drugs,  uraemia, 
and  the  specific  fevers.  (2)  Centric  disease,  as  cerebral 
tumors  and  meningitis ;  this  type  is  often  unaccompanied 
with  nausea,  and  does  not  relieve  the  associated  headache. 
(3)  Diseases  of  the  stomach,  as  ulcer,  cancer,  dilatation,  dys- 
pepsia, etc.  (4)  Reflex,  as  from  pregnancy,  uterine  or  ovarian 
disease,  irritation  of  the  fauces,  worms,  biliary  colic,  etc.  (5) 
Intestinal  obstruction ;  this  is  often  fecal.  (6)  Disturbed  cere- 
bral circulation,  as  in  swinging  and  sea-sickness.  (7)  Certain 
nervous  aifections,  as  hysteria,  migraine.  (8)  Periodic  vomit- 
ing may  be  in  itself  a  neurosis,  or  may  be  associated  with  the 
gastric  crises  of  locomotor  ataxia.  (9)  CEsophageal  vomiting 
results  from  obstruction,  and  the  vomit  is  alkaline  in  reaction^ 


20  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 


THE  VOMIT. 

Watery,  or  mucous  vomit,  is  noted  in  chronic  gastritis,  in 
certain  forms  of  nervous  dyspepsia,  and  after  persistent  emesis, 
as  in  cholera. 

Bilious,  or  green  vomit,  is  not  diagnostic  of  any  special  con- 
dition ;  it  Diay  occur  in  any  case  where  vomiting  and  straining 
are  continued. 

Bloody  vomit  (HcBmatemesis).— For   causes,   see   page  50. 
When    present   in  large    amount  the  blood  can   usually  he 
recognized  by  the  unaided  eye ;  small  amounts  may  be  de-  • 
tected  by  the"^  microscope,  spectroscope,  or  by  chemical  tests. 

Test  for  blood. — Evaporate  some  of  the  filtered  coffee-grounds 
vomit  in  a  watch-glass,  scrape  off  some  of  the  dried  material ; 
add  a  trace  of  finely-pulverized  salt;  place  the  mixture  on  an 
object-glass,  and  cover.  Allow  one  or  two  drops  of  glacial 
acetic  acid  to  run  under,  and  again  evaporate ;  when  dry  allow 
one  or  two  drops  of  distilled  water  to  flow  under  to  dissolve 
the  crystals  of  salt.  Under  the  microscope  minute  brown 
rhombic  crystals  of  hsematin  appear. 

Purulent  vomit  may  result  from  the  rupture  of  an  abscess 
into  the  oesophagus  or  stomach,  or  from  phlegmonous  gastritis. 

Fecal  vomit  (stcrcoraceous)  is  indicative  of  iutestiual  obstruc- 
tion.    It  is  recognized  by  its  odor  and  appearance. 

Profuse  vomit— The  ejection  of  large  quantities  of  frothy 
fermented  material  is  highly  significant  of  gastric  dilatation. 

Vomiting  without  nausea,  distress,  or  other  gastric  phenomena, 
occurs  in  certain  neuroses  of  the  stomach,  in  hysteria,  ursemia, 
and  in  brain  disease,  as  tumor,  or  as  a  precursor  of  apoi)lexv. 


EXAMINATION    OF   THE    GASTRIC    CONTENTS.  21 

EXAMINATION     OF     THE     GASTRIC 
CONTENTS. 

The  test-meal  recommended  by  Ewald  consists  of  an  ordi- 
nary dry  roll  and  two-thirds  of  a  pint  of  water  or  weak  tea, 
without  milk  or  sugar.  One  hour  after  the  ingestion  of  this 
meal  about  40  c.cm.  of  fluid  should  be  obtained  from  the 
stomach  by  expression.  When,  however,  lactic  acid  as  a 
pathological  element  is  sought  for,  it  is  necessary  to  prescribe 
a  meal  which  contains  no  preformed  lactic  acid.  The  one  rec- 
ommended by  Boas  is  now  commonly  employed  ;  it  is  a  flour- 
sonp  consisting  of  a  tablespoonful  of  oatmeal  to  a  litre  of  water, 
and  flavored  with  a  little  salt.  Before  administering  this  meal 
the  stomach  should  be  thoroughly  cleansed  of  any  existing 
residue  that  might  mar  the  result  of  the  test. 

Test  for  Free  Acids. — Filter-paper  soaked  in  a  solution 
of  Congo-red,  and  dried,  turns  blue  in  the  presence  of  free 
acids.  A  saturated  alcoholic  solution  of  tropseolin  00  turns 
from  a  brownish  yellow  to  a  dark  brown  when  brought  in  con- 
tact with  fluids  containing  free  acids. 

Qualitative  Tests  for  HCl. — Giinzsburg's  phloroglucin- 

vanillin  test  will  react  with  1  part  of  HCl  in  15,000  parts  of 
water.  The  solution  consists  of  2  parts  of  phlorogluciu,  1  part 
of  vanillin,  and  30  parts  of  absolute  alcohol.  When  a  few 
drops  of  this  solution  are  heated  with  an  equal  quantity  of  the 
filtrate  contained  in  a  porcelain  dish,  a  beautiful  red  color  ap- 
pears at  the  margin  of  the  fluid.  Boas  states  that  the  test  is 
still  more  delicate  when  100  parts  of  80  per  cent,  alcohol  are 
substituted  for  the  30  parts  of  absolute  alcohol. 

Boas'  resorcin-sugar  test  gives  a  similar  reaction.  The  re- 
agent consists  of  5  parts  of  resorcin,  3  parts  of  sugar,  and  100 
parts  of  diluted  alcohol. 

Total  Acidity. — This  is  determined  by  allowing  a  deci- 
normal  alkali  solution  (water  10  c.cm.,  hydrate  of  potassium 
56  milligrammes)  to  flow  from  a  burette,  drop  by  drop,  into  a 
beaker  containing  10  c.cm.  of  filtered  gastric  juice,  to  which  have 
been  added  as  an  indicator  two  drops  of  an  alcholic  solution  of 


22  DISEASES    OF   THE   DIGESTIVE   SYSTEM. 

pheuol-phtlialeiu.  The  test  is  completed  when  the  red  color 
produced  no  longer  disappears  on  shaking  the  sokition.  Ten 
c.cm.  of  normal  gastric  juice  usually  require  from  4  to  6.5 
ccm.  of  the  standard  alkali  solution. 

Since  1  c.cm.  of  the  alkali  solution  is  equivalent  to  0.00364 
gramme  of  HCl,  it  follows  that  the  jiercentage  of  the  latter  in 
a  given  sj)ecimen  will  equal  the  number  of  c.cm.  of  the  alkali 
solution  required  multiplied  by  10,  and  again  by  0.00364. 

Test  for  Lactic  Acid. — Dilute  solutions  of  neutral  ferric 
chloride  turn  canary  yellow  in  the  presence  of  lactic  acid. 
TJffehnann^s  reagent  is  made  by  mixing  one  or  two  drops  of 
pure  carbolic  acid  with  a  few  drops  of  dilute  solution  of  neutral 
ferric  chloride,  and  adding  sufficient  water  to  turn  the  solution 
a  beautiful  amethyst-blue  color.  Unfortunately  other  sub- 
stances, such  as  sugar,  alcohol,  acid  phosphates,  and  tartaric 
acid,  give  a  somewhat  similar  reaction.  The  test  is  made  more 
reliable  by  exhausting  a  portion  of  the  gastric  filtrate  with 
pure  ether,  evaporating  the  ethereal  extract,  and  finally  testing 
an  aqueous  solution  of  the  residue. 

Boas^  test,  though  somewhat  complicated,  is  far  more  reliable. 
The  gastric  contents  secured  after  the  ingestion  of  the  flour- 
soup  test-meal  are  filtered,  and  if  the  presence  of  free  acids  be 
indicated  by  Congo-red,  an  excess  of  barium  carbonate  is  added. 
The  filtrate  is  then  evaporated  to  the  consistence  of  syrup,  and 
the  COg  is  driven  off  by  boiling  with  a  few  drops  of  phos- 
phoric acid.  The  mixture  is  then  thoroughly  exhausted  with 
ether  that  is  absolutely  free  from  alcohol,  the  ethereal  extract 
evaporated,  and  the  residue  dissolved  in  45  c.cm.  of  water. 
The  aqueous  solution  is  poured  into  a  flask,  and  treated  with 
5  c.cm.  of  sulphuric  acid  and  a  small  quantity  of  manganese 
dioxide.  A  bent-glass  tube  is  made  to  connect  the  flask  with 
a  mixture  of  equal  parts  of  a  deci-normal  iodine  solution  and 
a  deci-normal  sodium  hydrate  solution.  On  heating  the  con- 
tents of  the  flask  to  the  boiling-point,  the  alkaline  iodine  solu- 
tion becomes  smoky  and  the  odor  of  iodoform  is  detected  when 
lactic  acid  is  present. 

Test  for  Acetic  Acid. — This  acid  may  be  detected  by  its 
odor.  The  production  of  a  blood-red  color  on  the  addition  of 
a  neutral  solution  of  ferric  chloride  to  an  aqueous  solution  of 


EXAMINATION    OF   THE    GASTRIC   CONTENTS.  23 

the  ethereal  extract  which  has  been  neutralized  with  sodium 
carbonate  also  indicates  the  presence  of  acetic  acid. 

Test  for  Butyric  Acid. — This  acid  strikes  a  brownish- 
yellow  color  with  Uifelmann's  reagent.  Its  odor  is  also  cha- 
racteristic. 

Test  for  Peptones  and  Propeptones. — These  substances 

are  the  products  of  albumin  digestion,  and  may  be  detected  by. 
the  biwet  test.  When  potassium  hydrate  and  dilute  copper  sul- 
phate are  added  to  a  solution  of  peptone  a  deep  purple-red  color 
is  struck.  With  ])ropeptone  the  reaction  is  the  same  ;  with  al- 
bumin, however,  the  color  is  bluish-violet.  The  amount  of 
peptone  may  be  roughly  estimated  by  first  precipitating  the 
albumin  and  propeptone  by  saturating  the  filtrate  with  crys- 
tals of  ammonium  sulphate,  and  then  noting  the  intensity  of 
the  color  reaction  with  the  biuret  test. 

Test  for  Rennet. — This  may  detected  by  adding  to  10 
c.cm.  of  unboiled  milk  having  a  neutral  reaction  an  equal  quan- 
tity of  neutralized  filtrate.  When  the  mixture  is  treated  in  a 
water  bath  to  a  temperature  of  30°  to  40°  C,  a  cake  of  casein 
forms  in  from  15  to  20  minutes. 

Test  for  Pepsin. — Ewald  recommends  the  following 
method  of  determining  in  a  given  specimen  whether  the  pep- 
sin or  hydrochloric  acid  is  present  in  too  great  or  too  small 
amount :  An  equal  quantity  of  the  filtrate  is  placed  in  four 
small  test-tubes,  and  a  disk  of  coagulated  white  of  egg  put 
into  each.  To  the  first  nothing  else  is  added ;  to  the  second 
2  drops  of  hydrochloric  acid  is  added  for  each  6  c.cm.  of  stom- 
ach contents;  to  the  third  from  0.2  to  0.5  gramme  of  pepsin 
is  added  ;  and  to  the  fourth  both  the  hydrochloric  acid  and 
pepsin  are  added.  The  test-tubes  are  then  placed  in  an  incu- 
bator at  about  100°  F.  The  rapidity  with  which  the  albu- 
min is  liquefied  in  the  different  tubes  will  indicate  whether 
digestion  would  have  occurred  without  having  added  anything, 
or  whether  acid  or  pepsin  or  both  were  necessary. 

Test  for  Carbohydrates. — In  health  the  digestion  of 
starch  is  practically  completed  within  an  hour;  after  that  time 
dextrins,  maltose,  and  dextrose  should  be  found  instead  of 
starch.  If  the  last  substance  remain  undigested  it  may  be 
detected  by  the  blue  color  which  it  strikes  with  Lugol's  solu- 


24  DISEASES   OF   THE    DIGESTIVE   SYSTEM. 

tioii.     With  erythrodextrin  the  iodine  sokition  gives  a  purple 
color,  but  with  maltose  and  dextrose  there  is  no  reaction. 

The  Absorptive  Power  of  the  Stomach. — This  is  de- 
termined by  the  time  required  for  free  iodine  to  appear  in  the 
saliva  after  the  ingestion  of  potassium  iodide.  The  saliva  is  re- 
ceived on  filter-paper  impregnated  with  starch,  a  drop  or  two 
.of  fuming  nitric  acid  is  then  added,  and  the  appearance  of  a 
blue  color  proclaims  the  presence  of  iodine.  Normally  the 
saliva  should  yield  the  reaction  for  iodine  in  from  ten  to  fif- 
teen minutes  after  the  ingestion  of  a  capsule  containing  0.1 
gramme  of  potassium  iodide.  Care  must  be  taken  that  none 
of  the  drug  adheres  to  the  outside  of  the  capsule. 

The  Motor  Power  of  the  Stomach. — Ewald  has  sug- 
gested the  use  of  salol,  which  escapes  from  the  stomach  into 
the  intestine,  where  it  is  broken  up  into  salicylic  acid  and 
phenol.  Normally  salicyluric  acid  appears  in  the  urine  in 
from  forty  to  seventy-five  minutes  after  the  ingestion  of  one 
gramme  of  salol.  Filter-paper  moistened  with  urine  contain- 
ing salicyluric  acid  assumes  a  violet  color  when  treated  with  a 
10  per  cent,  ferric  chloride  solution. 

ACIDITY  OF  THE  GASTRIC  CONTENTS. 

Normal  acidity  is  due  to  hydrochloric  acid,  but  other  acids 
are  frequently  formed  during  the  digestive  process,  such  as 
lactic,  butyric,  and  acetic  acids.  The  quantity  of  hydrochloric 
acid  in  normal  gastric  juice  varies  from  0.14  to  0.24  per  cent., 
more  acid  being  secreted  after  a  heavy  meal  than  after  a  light 
one. 

Hyperacidity. — This  condition  is  noted  in  chlorosis,  in  gas- 
tric ulcer,  and  in  certain  forms  of  nervous  dyspepsia. 

Subacidity  or  inacidity  occurs  :  (1)  In  certain  nervous  aifec- 
tious,  as  in  some  forms  of  nervous  dyspepsia,  hysteria,  and 
neurasthenia.  (2)  In  extreme  anaemia.  (3)  In  gastric  catarrh. 
(4)  In  gastric  cancer.  (5)  In  acute  febrile  diseases.  (6)  Often 
in  passive  congestion  of  the  stomach,  as  from  chronic  heart  and 
liver  disease. 


ABDO.MlxNAL    PAIN    AA'D    TE^DER^IESS.  20 


RUMINATIOIV,  OR  MERYCISMUS. 

Rumiuatiou  is  a  condition,  rarely  observed  in  man,  in  which 
the  food  is  regurgitated  from  the  stomach  and  subjected  to  a 
second  mastication.  It  is  the  result  of  a  neurosis,  and  is  gen- 
erally found  in  association  with  hysteria,  epilepsy,  neurasthe- 
nia, or  idiocy.  It  is  sometimes  hereditary,  or  acquired  by 
imitation. 

HICCOUGH. 

Hiccough,  or  singultus,  results  from  a  clonic  spasm  of  the 
diaphragm,  and  is  often  noted  as  a  temporary  condition  after 
eating  or  drinking.  Persistent  hiccough  is  sometimes  present 
in  extreme  exhaustion  following  acute  or  chronic  diseases.  It 
may  also  result  from  irritation  of  the  phrenic  nerve,  as  from 
the  pressure  of  a  thoracic  aneurism.  It  may  be  reflex  from 
stomachic,  hepatic,  intestinal,  or  peritoneal  disease.  It  may 
he  due  to  hysteria. 


abdomi:n^al  pain  and  tenderness. 

Diffuse  abdominal  tenderness  is  noted  in  peritonitis,  in  hys- 
teria, and  in  rheumatism  of  the  abdominal  muscles. 

Persistent  abdominal  pain  results  from  the  various  visceral 
diseases,  chronic  peritonitis,  abdominal  aneurism,  and  disease 
of  the  spinal  vertebrae. 

Colic  is  a  painful  spasm  of  a  mucous  canal.  The  common 
varieties  are — biliary,  intestinal,  renal,  uterine,  and  pancreatic. 

Painful  defecation  results  from  constipation,  anal  fissure, 
dysentery,  piles,  ulceration,  stricture,  jjrolapse  of  the  rectum, 
and  inflammatory  conditions  of  neighboring  organs,  as  the 
uterus  or  prostate  gland. 


26  DISEASES    OF    THE    DIGESTIVE   SYSTEM. 


THE  STOOLS. 

Blood  in  the  Stools  (Entrorrhagia  or  Melcena). 

The  blood  is  nearly  normal  in  appearance  after  profuse 
hemorrhages,  or  when  it  has  been  quickly  discharged,  as  in 
piles  and  fissure.  Retained  blood  imparts  a  black  or  tarry 
appearance  to  the  stools. 

Melsena  results  from:  (1)  Traumatism.  (2)  Acute  in- 
flammation of  the  bowels,  as  in  enteritis  and  dysentery.  (3) 
Obstructed  circulation,  as  in  chronic  heart  and  liver  disease. 
(4)  Vicarious  menstruation.  (5)  Blood  dyscrasia,  as  in  scurvy, 
purpura,  infectious  fevers,  etc.  (6)  Rupture  of  an  aneurism. 
(7)  Ulcers  in  the  intestines,  as  simple  duodenal  ulcer,  typhoid, 
dysenteric,  tubercular,  or  malignant  ulcers.  (8)  Intussuscep- 
tion. (9)  The  passage  of  blood  from  the  stomach  in  hsema- 
temesis.     (10)  Piles,  fissure,  fistula. 

Watery,  or  serous  stools  are  noted  in  choleraic  diseases,  in 
nervous  diarrhcea,  in  the  colliquative  diarrhoea  which  termi- 
nates wasting  diseases,  in  severe  enteritis,  and  in  corrosive 
poisoning,  as  by  arsenic,  antimony. 

Green  stools  may  result  from  an  excessive  amount  of  bile. 
They  are  also  common  in  the  diarrhoeas  of  young  children,' 
and  in  these  cases  the  green  color  may  be  due  to  bacterial 
growth.     (Hayem.) 

Black  stools  may  follow  intestinal  hemorrhage,  and  the  use 
of  certain  drugs,  as  charcoal,  bismuth,  iron,  tannin,  etc. 

Red  stools  usually  indicate  blood,  but  they  may  be  tinged  red 
after  the  administration  of  hsematoxylin  (logwood). 

llucous  stools  are  noted  in  intestinal  catarrh,  particularly 
when  the  lower  bowel  is  affected,  as  in  entero-colitis  and  dys- 
entery. 

Fatty  stools  result  from  the  ingestion  of  large  quantities  of 
fats,  from  the  absence  of  bile,  and  from  chronic  pancreatic 
diseases. 

Purulent  stools  result  from  fistula  in  ano,  dysenteric,  syphi- 
litic, or  malignant  ulceration,  or  the  rupture  of  abscesses  into 
the  bowel,  as  prostatic  and  ])elvic  abscesses. 


STOMATITIS.  27 

lAenteric  stools.  Stools  which  contain  much  undigested  food 
are  noted  in  inflammatory  conditions  of  the  stomach  and  upper 
bowel. 


ABDOMINAL  DLSTENTIOIN^. 

Causes. — (1)  Enlargement  of  the  various  organs  from 
tumors  or  other  causes.  Recognized  by  the  history,  irregular 
enlargement,  and  special  symptoms  referable  to  the  organ  af- 
fected. (2)  Ascites,  llecognized  by  movable  dulness  with 
superincumbent  tymjsany,  and  fluctuation.  (3)  Tympanites. 
Recognized  by  universal  tympany  on  percussion.  (4)  Preg- 
nancy. Recognized  by  suppression  of  menses,  morning  emesis, 
pigmentation  of  mammary  areola,  softening  of  the  cervix,  in- 
termittent uterine  contractions,  etc.  (5)  Distention  of  the 
bladder.  Recognized  by  the  history,  location  of  dulness,  and 
results  of  catheterization. 


STOMATITIS. 

Definition.' — Inflammation  of  the  mouth. 

Etiology. — (1)  Mechanical,  chemical,  thermal,  or  parasitic 
irritation.  (2)"  Mercurial  poisoning.  (3)  Cachectic  states,  as 
in  phthisis,  cancer,  and  diabetes.  (4)  It  is  most  commonly 
seen  in  young  children  in  association  with  gastro-intestinal 
disturbances,  brought  about  by  artificial  feeding,  warm  weather, 
and  bad  hygienic  surroundings. 

Varieties. — (1)  Catarrhal.  (2)  Aphthous.  (3)  Ulcerative. 
(4)  Parasitic  (thrush).     (5)  Gangrenous.     (6)  Mercurial. 

General  Symptoms. — Heat  and  pain  in  the  mouth,  in- 
creased flow  of  saliva,  fetor  of  the  breath,  restlessness,,  languor, 
disinclination  to  nurse,  and  perhaps  some  fever. 

Catarrhal  Stomatitis  {Simple  stomatitis). 

Symptoms. — General  symptoms  of  stomatitis,  and,  on  in- 
spection, a  difiiise  red  swelling  of  the  mucous  membrane. 

Treatment. — Good  hygienic  conditions.     Keep  the  mouth 


28  DISEASES    OF    THE    DIGESTIVE   SYSTEM. 

clean.  Employ  a  weak  solution  of  silver  nitrate,  boric  acid, 
or  chlorate  of  potassium  as  a  wash. 

Aphthous  Stomatitis  {Follicular  stomatitis,  Vesicular  stom- 
atitis). 

Symptoms. — General  symptoms  of  stomatitis,  and,  on  in- 
spection, numerous  small,  round  vesicles  on  the  cheeks,  lips, 
and  tongue  ;  these  vesicles  soon  break,  and  leave  little,  shallow 
ulcers  with  a  red  areola. 

Prognosis. — Good. 

Treatment. — Sterilize  the  milk.  Nurse  at  regular  inter- 
vals. Wash  the  mouth  with  a  clean  linen  cloth.  Correct 
any  gastric  disturbance.     Use  locally  : — 

^   Acid,  boric,  gr.  x-xx ; 
Glycerini,  13  ss; 
Aqufe,  q.  s.  ad  f^ij, — M. 
Chlorate  of  potassium  (gr.  xx-xxx)  may  be  substituted  for  the 
boric  acid. 

Ulcerative  Stomatitis. — This  is  thought  by  some  to  be  an 
infectious  disease,  because  it  often  occurs  in  epidemics,  and 
attacks  both  children  and  adults  when  congregated  and  sub- 
jected to  bad  hygienic  conditions. 

Symptoms. — General  symptoms  of  stomatitis. 

Inspection. — The  gums  of  the  lower  jaw  are  chiefly  affected. 
They  are  swollen,  red,  and  spongy.  Linear  ulcers,  with  gray, 
sloughing  bases  soon  form,  and  may  extend  to  the  cheek.  The 
glands  under  the  jaw  are  swollen.  In  severe  cases  loosening 
of  the  teeth  and  necrosis  of  the  bone  may  follow. 

Prognosis. — Guardedly  favorable. 

Treatment. — Correct  the  hygiene.  Tonic  doses  of  quinine 
by  the  stomach  or  rectum  are  indicated.  Touch  the  ulcers 
with  nitrate  of  silver,  apd  use  as  a  mouth-wash  a  solution  of 
chlorate  of  potassium  or  peroxide  of  hydrogen. 

Parasitic  {Thrush,  Muguet). 

Exciting  Cause. — Saccharomyces  albicans. 

Symptoms. — General  symptoms  of  stomatitis,  and,  on  in- 
spection, numerous  milk-white  elevations  which,  on  removal, 
leave  a  raw  surface.  The  disease  may  extend  to  the  pharynx, 
oesophagus,  and  larynx.  Microscopic  examination  reveals  the 
fungus. 


STOMATITIS.  29 

Prognosis. — Good. 

Treatment. — Correct  the  hygiene.  Treat  any  gastric  dis- 
turbance. Tonics  are  often  indicated.  Locally,  borax  is  of 
value,  and  may  be  used  in  the  following  mixture : — 

]^   Sodii  borat.,  3j  ; 
Glycerini,  foij  ; 
Aquse,  f3vj. — M. 
Sig. — Apply  several  times  daily  by  means  of  a  camel's-hair  brush. 

Gangrenous  Stomatitis  {Cancrum  oris,  Noma). — This  form 
is  usually  seen  in  debilitated  children  between  the  ages  of  two 
and  six  years,  and  usually  follows  one  of  the  specific  fevers, 
especially  measles  and  whooping-cough. 

Symptoms.  —  The  general  symptoms  of  stomatitis  are 
marked. 

Inspection. — The  cheek  is  the  part  affected.  Externally, 
it  is  swollen,  hard,  red,  and  glazed ;  internally,  there  is  noted 
an  irregular,  sloughing  ulcer. 

Complications. — Perforation,  septicaemia,  lobular  pneu- 
monia from  aspirated  sloughs,  and  diarrhoea  from  the  swal- 
lowing of  fetid  material. 

Prognosis. — Grave.  Death  is  common  from  exhaustion 
or  comjDlications.     Recovery  is  often  attended  with  deformity. 

Treatment. — Good  hygiene,  alcoholic  stimulants,  nutri- 
tious food,  tonics  like  iron  and  quinine. 

Locally. — Evert  the  cheek  and  apply  the  actual  cautery,  or 
pack  the  surrounding  parts  with  oiled  lint,  apply  to  the  ulcer 
strong  nitric  acid,  and  subsequently  neutralize  with  bicarbo- 
nate of  sodium.  As  a  mouth-wash,  peroxide  of  hydrogen  is  of 
distinct  value. 

Mercurial  Stomatitis  (Ptyalism). — This  form  of  stomatitis 
is  seen  in  artisans  who  work  in  mercury,  after  the  administra- 
tion of  very  large  doses  of  mercurials,  and  after  the  adminis- 
tration of  small  doses  when  there  has  been  an  unnatural 
susceptibility. 

Symptoms.  Premonitory  Symptoms. — Tenderness  of  the 
gums,  manifested  by  bringing  the  teeth  forcibly  together; 
redness  of  the  gums  near  the  insertion  of  the  teeth,  a  metallic 
taste,  and  an  increase  of  saliva. 


30  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

Later  Symptoms. — Profuse  salivation,  fetor  of  breath,  red- 
ness, swelling,  and  tenderness  of  the  gums.  The  tongue  may 
be  similarly  aifected  and  protrude  from  the  mouth.  In  severe 
cases  ulceration  of  the  mucous  membrane,  loss  of  teeth,  and 
necrosis  of  the  jaw  result. 

Treatment. — Use  astringent  and  antiseptic  mouth-washes. 
Employ  iodide  of  potassium  in  small  doses  to  eliminate  the 
mercury.  Opium  may  be  required  at  night  to  allay  distress. 
Belladonna  aids  in  arresting  the  secretion. 

TONSILIilTIS. 

(Amygdalitis.) 

Etiology. — Tonsillitis  occurs  at  all  ages,  but  it  is  particu- 
larly common  in  the  young. 

The  rheumatic  diathesis  exerts  a  predisposing  influence. 
Exposure  to  cold  and  wet  usually  excites  it,  and  such  exposure 
is  very  eifective  when  the  system  is  debilitated,  or  the  throat 
is  congested  from  improper  use  of  the  voice.  Impure  air,  as 
the  effluvium  from  foul  drains  or  sewers,  sometimes  excites  it. 

Varieties. — (1)  Simple,  or  catarrhal.  (2)  Follicular,  or 
lacunar.     (3)  Phlegmonous  (quinsy). 

Symptoms. — Pain  in  the  throat  increased  by  swallowing 
and  talking ;  marked  tenderness  beneath  the  angles  of  the  jaw ; 
and  fever  with  its  associated  phenomena ;  in  severe  forms  the 
temperature  is  quite  high,  104°  or  105°. 

In  the  catarrhal  form  the  tonsils  are  uniformly  swollen,  red, 
and  covered  with  tenacious  mucus. 

In  the  follicular  form  the  tonsils  are  red  and  swollen,  and 
present  little  yellow  spots  on  their  surfaces.  These  spots  are 
found  to  be  plugs  of  degenerated  epithelium  which  are  retained 
in  the  crypts  on  account  of  the  swelling  and  occlusion  of  their 
outlets.  These  plugs  are  often  expectorated  during  convales- 
cence as  offensive  cheesy  pellets. 

In  the  phlegmonous  form  the  tonsils  are  extremely  swollen, 
often  so  much  that  they  almost  meet;  "the  pain  is  intense  and 
of  a  throbbing  character.  One  gland  soon  becomes  largei" 
than  the  other,  softens,  fluctuates,  and  turns  yellow  from  sup- 
puration. Swallowing  is  almost  impossible,  the  voice  is  lost, 
and  breathino;  is  difficult. 


TONSILLITIS.  31 

Diagnosis. — In  children  tonsillitis  may  resemble  scarlet 
fever,  especially  when  the  former  is  associated  with  an  acci- 
dental rash. 

Scarlet  Fever. — History  of  contagion,  onset  with  vomiting, 
a  punctated  red  rash,  "  strawberry"  tongue,  albuminuria,  and 
pulse  too  rapid  to  be  proportionate  to  the  fever. 

Diphtheria. — The  follicular  form  resembles  diphtheria,  but 
in  the  latter  there  is  a  false  membrane,  not  only  on  the  tonsils 
but  on  surrounding  parts,  and  its  removal  leaves  behind  a 
raw  surface.  The  history  of  contagion,  the  rapid,  Aveak  pulse, 
the  marked  swelling  of  the  submaxillary  glands,  albuminuria, 
and  the  Klebs-LoflSer  bacillus,  detected  by  cultivation,  will 
also  indicate  diphtheria. 

Pno&NesiS. — Favorable  ;  even  in  grave  cases  rupture  of  the 
abscess  occurs  when  death  seems  imminent.  Suffocation  from 
rupture  during  sleep,  and  death  from  ulceration  of  the  carotid 
artery  are  extremely  rare  terminations. 

Treatment. — Rest,  light  diet,  and  protection.  In  the 
beginning,  salicylate  of  sodium  (gr.  xx  thrice  daily)  may  be 
given  to  shorten  the  attack.  The  ammoniated  tincture  of 
guaiacum  (5ij  every  two  hours)  is  a  very  efficient  remedy. 
The  benzoate  of  sodium  is  also  highly  recommended  : — 

]^   Sodii  henzoat.,  3j-3iv  ; 
Glycerin., 

Elix.  calisay.,  aa  fgj. — M. 
Sig. — A  teaspoonful  every  hour  or  two. 

In  some  cases  quinine  (gr.  v.  thrice  daily)  with  small  doses 
of  the  tincture  of  aconite  and  the  tincture  of  belladonna  is 
an  efficient  remedy. 

In  severe  cases  opium  is  often  required  to  relieve  pain  and  to 
produce  sleep. 

Local  Treatment. — Pellets  of  ice  give  much  relief.  The 
following  remedies  are  efficient :  Solutions  of  nitrate  of 
silver,  dry  bicarbonate  of  sodium,  guaiac  lozenges  (gr.  ij), 
saturated  ethereal  solution  of  iodoform.     Or : — 

^j^:.   Potass,  chlor.,  gr.  xx-xxx ; 
Tinot.  ferri  chlor., 
Glycerin. ,  aa  f,^  ss  ; 
Aqute,  q.  s.  ad  f^ij. — M. 
Sig. — Apply  several  times  daily  with  acamel's-hair  brush. 


32  DISEASES    OF   THE    DIGESTIVE   SYSTEM. 

When  the  glands  are  very  much  swollen  scarification  will 
lessen  the  pain  and  often  shorten  the  attack.  When  fluctua- 
tion is  detected  the  tonsil  should  be  incised  with  a  guarded 
bistoury. 

External  AppUaations. — An  ice-bag,  a  poultice,  or  iodine. 

HYPERTROPHY   OF  THE  TONSILS. 

Etiology. — Childhood,  the  rachitic  and  tubercular  dia- 
theses, and  repeated  attacks  of  acute  tonsillitis  are  the  predis- 
posing causes.     It  may  arise  without  obvious  cause. 

Pathology. — It  may  be  a  true  hypertrophy,  but  in  most 
instances  either  the  glandular  structure  or  the  connective 
tissue  predominates ;  and  the  firmness  of  the  gland  increases 
in  proportion  to  the  overgrowth  of  the  latter.  The  follicles 
are  often  dilated,  and  filled  with  cheesy  material  which  results 
from  the  accumulation  of  fatty-degenerated  epithelium.  Naso- 
pharyngeal catarrh  and  adenoid  growths  in  the  naso-pharynx 
are  often  associated  conditions. 

Symptoms. — Difficult  swallow^ing,  mouth-breathing,  snor- 
ing during  sleep,  a  thick  voice  with  a  nasal  twang  to  it,  and 
malnutrition.  Sufferers  are  very  prone  to  acute  attacks  of 
catarrh  of  the  nose  and  throat.  In  severe  cases,  from  inter- 
ference with  breathing,  the  chest  assumes  the  rachitic  type — 
that  is,  flattened  at  the  sides  and  base  and  prominent  over  the 
sternum. 

Peognosis. — Favorable  under  prolonged  and  careful  treat- 
ment. 

Treatment.  General  Treatment. — Build  up  the  tone  of  the 
patient  by  frequent  bathing  with  salt  water,  followed  by  fric- 
tion, light  gymnastics,  deep  breathing,  and  by  the  use  of 
nutrient  tonics  such  as  cod-liver  oil,  hypophosphites,  and 
iodide  of  iron. 

Local  Treatment. — A  solution  of  nitrate  of  silver,  or  LugoPs 
solution  (liquor  iodi  compositus),  may  be  applied  frequently  to 
the  tonsils;  or  dilute  acetic  acid  (gtt.  ij)  or  a  dilute  solution 
of  iodine  (gtt.  ij)  may  be  injected  into  the  tonsils.  When  the 
glands  are  very  large  they  should  be  removed  by  the  tonsil- 
lotome,  scissors,  or   galvano-cautery.       Pharyngeal   adenoids 


PHARYNGITIS.  33 

should  likewise  be  removed  by  the  finger-nail  or  curette 
while  the  patient  is  under  the  influence  of  some  general  anaes- 
thetic, or  after  the  parts  have  been  treated  with  cocaine. 

PHARYNGITIS. 

Acute  Pharyngitis  (Acute  "  sore  throat/'  Simple  angina). 

Definition. — An  acute  catarrhal  inflammation  of  the 
mucous  membrane  of  the  pharynx,  soft  palate,  and  uvula,  and 
frequently  associated  with  tonsillitis  and  laryngitis. 

Etiology. — Exposure  to  cold  and  wet,  especially  when  the 
system  is  debilitated  or  the  throat  is  congested  from  improper 
use  of  the  voice.  It  may  be  rheumatic  in  origin.  It  may  be 
excited  by  local  irritants,  such  as  hot  drinks  or  the  inhalation 
of  noxious  gases. 

Exposure  to  infectious  fevers,  like  scarlatina  and  measles, 
may  be  followed  by  simple  pharyngitis. 

Symptoms, — Chilliness  and  slight  fever  with  its  associated 
phenomena;  soreness  in  the  throat,  painful  deglutition,  a  sen- 
sation of  dryness  or  tickling,  with  a  hacking  cough ;  stiffness 
and  tenderness  of  the  muscles  of  the  neck.  Extension  to  the 
larynx  may  cause  hoarseness ;  to  the  ear,  through  the  Eusta- 
chian tube,  deafness.  Inspection  reveals  a  red  and  swollen 
mucous  membrane. 

Varieties. — (1)  Simple;  recognized  by  the  above  symp- 
toms. (2)  Rheumatic  ;  recognized  by  the  history,  intense  pain, 
and  stiffness  of  the  muscles,  without  much  change  in  the  local 
appearance.  (3)  Follicular;  the  mucous  membrane  is  red, 
swollen,  and  covered  with  whitish  spots  which  represent  re- 
tained secretion  in  the  inflamed  follicles.  (4)  Infectious  pharyn- 
gitis is  the  form  associated  with  the  infectious  fevers. 

Prognosis. — Favorable. 

Treatment. — Light  diet  and  avoidance  of  exposure.  Hot 
drinks,  followed  by  Dover's  powder  (gr.  x),  and  a  saline  purge 
will  sometimes  abort  it. 

Tincture  of  aconite  (gtt.  ij)  with  tincture  of  belladonna  (gtt. 
v)  every  two  hours  is  sometimes  useful.     In  the  rheumatic 
form  the  salicylate  or  benzoate  of  sodium  is  very  efficient. 
3 


34  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

In  simple  angina  Pepper  recommends : — 

^  Potass,  chlorat.,  ^iss-ij  ; 
Potass,  bromid.,  §ss; 
Ext.  belladonnee,  gr.  iij-v  *, 
Syr.  limonis,  f.^j  ; 
Syrupi,  q.  s.  ad  f^iv. — M. 
Sig. — Teaspoonful  thrice  daily. 

Local  Remedies. — A  steam  spray,  pellets  of  ice,  a  gargle 
of  chlorate  of  potassium  (gr.  x  to  f  3j),  the  application  of  a 
solution  of  nitrate  of  silver  (gr.  v  to  f 5J),  or  lozeuges  of 
cocaine,  chloride  of  ammonium,  or  chlorate  of  potassium. 

Chronic  Pharyngitis. 

Etiology. — Chronic  "  sore  throat"  usually  results  from  re- 
peated acute  attacks,  improper  use  of  the  voice,  or  the  con- 
tinuous action  of  irritants,  like  tobacco  smoke. 

Varieties. — (1)  Hypertrophic.  (2)  Atrophic.  (3)  Ulcer- 
ative.    (4)  Phlegmonous. 

Symptoms. — The  voice  is  husky  and  its  use  is  followed  by 
distress  ;  secretion  is  increased  so  that  there  is  a  constant  desire 
to  clear  the  throat ;  disagreeable  sensations,  as  fulness,  tickling, 
and  the  like,  are  frequently  noted. 

In  the  hypertrophic  form  (granular  sore  throat,  clergyman's 
sore  throat,  chronic  follicular  pharyngitis)  the  mucous  mem- 
brane is  thick,  swollen,  traversed  by  dilated  veins,  and 
studded  with  numerous  elevations  which  are  composed  of  dis- 
tended follicles  and  overgrown  lymphatic  tissue. 

In  the  atrophic  form  (Pharyngitis  Sicca),  the  mucous  mem- 
brane is  pale,  smooth,  glossy,  and  dry. 

Ulcerative  Pharyngitis. — Ulceration  may  be  due  to  simple 
inflammation,  syphilis,  tuberculosis,  cancer,  and  lupus. 

Phlegmonous  Pharyngitis  (Retropharyngeal  abscess). — Sup- 
purative inflammation  of  the  retropharyngeal  connective  tissue 
may  occur  as  a  sequel  to  one  of  the  infectious  fevers,  or  may 
be  due  to  caries  of  the  cervical  vertebrae,  or  to  the  impaction 
of  a  foreign  body. 

It  may  be  recognized  by  sore  throat,  weak  voice,  difficult 
deglutition,  and  the  results  of  a  digital  examination. 

Treatment. — Chronic  pharyngitis  does  not  result  so  much 


STENOSIS   OF  THE   (ESOPHAGUS.  35 

from  excessive  use  of  the  voice  as  from  its  improper  use,  and 
uutil  this  is  corrected  no  treatment  will  be  successful.  Pa- 
tients should  be  instructed  to  expel  sounds  by  the  aid  of  the 
diaphragm  and  abdominal  muscles,  instead  of  the  muscles  of 
the  throat  and  larynx.  The  habit  of  hawking  and  scraping 
to  clear  the  throat  must  be  rigidly  interdicted.  The  patient 
must  guard  against  mouth-breathing.  Sponging  the  neck 
night  and  morning,  first  with  tepid,  then  with  cold  water,  will 
render  the  throat  less  sensitive.  The  general  health  will  re- 
quire attention,  and  such  tonics  as  iron,  quinine,  strychnine 
may  be  very  useful. 

Local  treatment. — The  naso-pharynx  should  be  kept  clean 
by  frequent  spraying  or  douching  with  some  antiseptic  solu- 
tion like  the  following  : — 

^   Sodii  bicarb., 

Sodii  biborat.,  aa  gr.  xx  ; 

Acid,  carbolic,  gtt.  vj  ; 

Glycerin.,  fsvj  ; 

Aquae,  q.  s.  ad  f§vj. — M.     (Dobell.) 

The  nasal  chambers  should  be  inspected  and  any  existing 
disease  treated. 

Astringent  applications  are  often  useful ;  solutions  of  nitrate 
of  silver,  five  or  ten  per  cent.,  sulphate  of  zinc,  or  tannic 
acid,  ten  to  twenty  per  cent.,  may  be  employed  for  this  pur- 
pose. Lymphatic  hypertrophies  should  be  removed  by  the 
galvano-cautery. 

Retropharyngeal  abscesses  will  require  evacuation  and  treat- 
ment directed  to  the  cause. 

Ulcerative  pharyngitis  will  require  appropriate  constitu- 
tional treatment,  and  such  local  remedies  as  nitrate  of  silver, 
iodoform,  nitric  acid,  etc. 

STENOSIS  OF  THE  (ESOPHAGUS. 

Vaeieties. — (1)  Functional  obstruction,  due  to  spasm 
(oesophagisraus).     (2)  Organic  obstruction. 


36  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 


SPASM  OF  THE  (ESOPHAGUS. 

Etiology. — Female  sex  ;  nervous  temperament ;  hysteria ; 
reflex  irritation.  It  may  occur  as  a  symptom  of  hydrophobia, 
tetanus',  and  organic  oesophageal  obstruction. 

Symptoms  of  Simple  (Esophageal  Spasm. — Paroxysmal 
dysphagia,  often  associated  with  a  sense  of  constriction  in  the 
chest ;  little  or  no  loss  of  flesh.  An  (Esophageal  bougie  can 
be  passed  without  much  difficulty. 

Diagnosis. — The  age  and  sex  of  the  patient,  the  parox- 
ysmal character  of  the  obstruction,  the  ability  to  pass  a  bougie, 
the  absence  of  wasting,  and  the  absence  of  any  other  cause, 
will  serve  to  separate  it  from  organic  obstruction. 

Prognosis. — Good  for  life,  but  indefinite  as  regards  dura- 
tion. 

Treatment. — Search  for  some  exciting  cause  and  remove 
it  when  possible.  The  treatment  is  largely  dietetic,  hygienic, 
and  moral.  Tonics  like  iron,  arsenic,  and  quinine  are  often 
indicated,  and  may  be  combined  with  such  antispasmodics  as 
valerian,  asafoetida,  or  sumbul.  The  systematic  passage  of  a 
bougie  may  be  of  great  value.  A  mild  electrical  current  may 
be  applied  through  the  bougie. 

ORGANIC  aj:SOPHAGEAE  OBSTRUCTION. 

Etiology. — (1)  An  external  tumor  pressing  on  the  oesoph- 
agus. This  is  most  commonly  an  aneurism.  (2)  A  tumor 
growing  from  the  oesophageal  wall ;  generally  a  cancer.  (3) 
A  cicatrix,  from  ulceration.  The  ulcer  may  be  due  to  syph- 
ilis or  to  some  corrosive  poison,  as  a  strong  acid  or  alkali. 
(4)  A  foreign  body. 

Symptoms. — A  slowly  increasing  difliculty  in  deglutition, 
with  the  regurgitation  of  food.  The  oesophagus  is  often  much 
dilated  above  the  constriction,  and  the  food  may  collect  in  the 
pouch  thus  formed,  so  that  regurgitation  may  be  delayed  for 
several  hours.  The  passage  of  a  bougie  meets  with  a  perma- 
nent obstruction.     There  is  much  loss  of  flesh. 

Diagnosis. — The  history  of  syphilis  or  corrosive  poisoning 
will  suggest  a  cicatrix.     Aneurismal  obstruction  can  usually 


ACUTE   GASTRITIS.  37 

be  detected  by  physical  examination.  Aneurism  should  be 
excluded  before  a  bougie  is  passed.  The  age,  cachexia,  pain, 
and  involvement  of  other  organs  will  indicate  cancer. 

Peognosis. — Depends  on  the  cause.  It  is  unfavorable  in 
aneurism  and  cancer.  In  cicatricial  contraction  the  obstruc- 
tion may  be  overcome  for  an  indefinite  period. 

Treatment. — Aneurism  :  Prolonged  rest,  restricted  diet, 
and  potassium  iodide.  Cicatricial  contraction  :  Systematic  dil- 
atation with  graduated  bougies.  Cancer :  In  the  early  stage, 
the  cautious  use  of  a  bougie  is  advisable.  In  advanced  cases 
the  patient  may  be  fed  through  a  tube,  and  when  this  is  no 
longer  possible,  life  may  be  prolonged  for  a  short  time  by 
rectal  alimentation  or  by  feeding  through  a  gastric  fistula. 

ACUTE  GASTRITIS. 

(Acute  Gastric  Catarrh.) 

Etiology. — (1)  Ingestion  of  indigestible  food,  especially 
when  followed  by  exposure  to  cold  and  wet.  (2)  Toxic  sub- 
stances in  excess,  as  alcohol,  strong  acids,  and  alkalies.  (3)  It 
is  an  associated  condition  in  certain  infectious  diseases,  as  yel- 
low fever,  measles,  and  scarlet  fever. 

Pathology. — The  mucous  membrane  is  red,  swollen,  and 
covered  with  thick  mucus.  It  is  sometimes  the  seat  of  ecchy- 
moses. 

Symptoms. — The  symptoms  vary  much  in  degree.  In  se- 
vere cases  there  may  be  moderate  fever  (102°-103°)  and  its  asso- 
ciated phenomena,  with  anorexia,  coated  tongue,  intense  pain 
in  the  epigastrium,  which  is  tender  to  the  touch,  persistent 
vomiting,  thirst,  and  considerable  prostration.  Jaundice  may 
follow  from  the  extension  of  the  catarrh  to  the  bile-ducts,  and 
diarrhoea  from  its  extension  to  the  intestines. 

Diagnosis. — It  may  resemble  the  onset  of  scarlet  fever,  but 
the  history  of  contagion,  the  "  strawberry  tongue,"  sore  throat, 
very  rapid  pulse,  and  eruption,  characterize  the  latter. 

Prognosis. — Usually  favorable ;  it  rarely  lasts  more  than  a 
few  days. 

Treatment. — Absolute  rest.  If  the  stomach  has  not  been 
completely  emptied,  an  emetic  such  as  ipecac  may  be  employed. 


38  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

Locally,  a  mustard  plaster  or  a  turpentiDe  stupe  will  aid  in 
relieving  the  distress.  In  severe  cases  no  food  should  be 
given  by  the  mouth  until  the  stomach  becomes  retentive. 
Thirst  should  be  allayed  with  cracked  ice.  Later,  milk  with 
lime-water  (a  teaspoonful  of  each)  may  be  given  hourly,  and 
this  may  be  followed  by  light  broths  in  similar  quantities. 

Persistent  vomiting  may  be  relieved  by  small  doses  of  calo- 
mel (gr.  -^^),  bismuth  (gr.  v.-x.),  carbolic  acid  (gtt.  ^-^),  or 
wine  of  ipecac  (gtt.  ] ). 

^  Hydrarg.  chlor.  mitis,  gr,  j  ; 

Bismuth,  subnit.,  3j, — M, 
Ft.  in  chart.  No,  xij. 
Sig,  — One  every  hour. 

Or, 

^  Creosoti,  gtt,  uj  ; 

Bismuth,  subnit,,  3J. — M. 
Ft.  in  chart.  No.  xij. 
Sig. — One  every  hour. 

Or, 

]^  Vin.  ipecac, 

Tinct.  nucis  vora.,  aa  f^j. — M.     (Pepper.) 
Sig. — Two  drops  in  water  every  two  hours. 

Severe  pain  and  obstinate  vomiting  will  often  yield  to  opium, 
in  the  form  of  suppositories.     Thus  :— 

^  Pulv.  opii,  gr.  vj  ; 

01.  theobrom.,  q.  s. — M. 
Ft.  in  suppos.  No.  vj. 
Sig. — One  every  three  hours. 

Toxic  gastritis  will  require  in  addition  appropriate  anti- 
dotes. 

DYSPEPSIA. 

Definition. — The  word  dyspepsia  means  ill  digestion,  and 
is  applied  to  a  group  of  symptoms  which  accompanies  every 
disease  of  the  stomach  ;  when,  however,  the  symptoms  depend 
on  nothing  more  than  simple  atony,  hypersensitiveness,  or 
chronic  catarrh,  the  condition  is  spoken  of  as  a  distinct 
affection. 

Corresponding    to    the    latter  view,   three    varieties    have 


DYSPEPSIA.  39 

been  recognized,  viz. :  (1)  Atonic.  (2)  Nervous,  and  (3) 
Catarrhal  dyspepsia. 

Etiology. — (1)  Heredity.  (2)  All  visceral  diseases,  as 
heart,  liver,  aud  kidney  disease.  (2)  Overwork,  mental  or 
physical.  (4)  Gastric  irritants,  as  tea,  coffee,  and  alcohol  in 
excess.  (5)  Dietetic  errors,  which  include — insufficient  mas- 
tication from  bad  teeth  or  hurried  eating,  too  much  food,  in- 
sufficient food,  coarse  or  improperly  cooked  food,  excessive 
dilution  of  food  with  liquids,  excess  of  condiments,  and  irreg- 
ular eating. 

Symptoms  op  Dyspepsia. — Coated  tongue,  perverted  ap- 
petite, fulness  and  distress  after  eating,  eructations,  flatulence, 
"  heart-burn,"  palpitation,  headache,  vertigo,  disturbed  sleep, 
and  lassitude. 

ATONIC  DYSPEPSIA. 

Characteristic  Symptoms. — The  tongue  is  pale,  coated, 
flabby,  and  tooth-marked  ;  the  appetite  is  lost ;  there  is  a  sense 
of  fulness  and  distress  over  the  stomach,  some  time  after  eating, 
without  actual  pain  or  tenderness.  The  bowels  are  constipated. 
There  is  much  flatulence.  The  patient  is  pale,  the  muscles 
are  soft,  the  pulse  is  weak,  and  there  is  great  lassitude. 

Prognosis. — G  ood. 

Treatment. — The  diet  must  be  carefully  regulated,  and 
rich  and  heavy  food  rigidly  interdicted.  The  hygienic  sur- 
roundings must  be  so  modified  that  the  general  condition  of 
the  patient  will  be  improved.  Tonics  like  iron,  quinine,  and 
strychnine  are  often  indicated.  Dilute  mineral  acids  with 
pepsin  will  be  required  to  assist  the  digestive  process. 

Purgatives  should  be  avoided,  and  constipation  relieved  by 
diet,  mineral  waters,  enemas,  or  suppositories. 

NERVOUS  DYSPEPSIA. 

This  type  usually  occurs  in  those  of  a  distinctly  nervous 
temperament,  and  excessive  mental  strain  and  dietetic  errors 
are  potent  etiological  factors.  It  is  frequently  associated 
with  neurasthenia  and  hysteria. 


40  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

Chaeacteeistic  Symptoms. — The  tongue  is  often  clean. 
The  appetite  is  very  irregular — at  one  time  it  is  lost ;  at  an- 
other it  is  inordinate ;  at  another  it  is  perverted,  the  patient 
craving  an  unnatural  diet.  Vomiting  is  not  common,  but  it 
may  occur  irrespective  of  the  time  of  eating  or  of  the  char- 
acter of  the  food.  Pain  is  very  variable,  and  may  appear 
when  the  stomach  is  empty  or  full.  In  some  cases  peristaltie 
unrest  is  a  prominent  symptom.  It  is  characterized  by  exag- 
gerated peristaltic  movements,  perceptible  to  the  patient,  with 
borborygmi  and  gurgling.  Gastric  acidity  is  usually  normal, 
but  there  may  be  subacidity  or  hyperacidity.  The  com- 
pletion of  the  digestive  act  in  the  normal  time  after  a  test- 
meal  is  highly  suggestive. 

Other  nervous  phenomena  are  commonly  present,  such  as 
headache,  vertigo,  disturbed  sleep,  hypochondriasis,  neuralgia, 
palpitation,  and  perverted  sensations. 

Diagnosis. — The  history,  associated  nervous  phenomena, 
the  time  that  the  pain  appears,  the  periods  of  complete  relief, 
the  absence  of  hemorrhage,  cachexia,  tumor,  and  local  tender- 
ness, are  the  chief  diagnostic  points. 

Prognosis. — Good,  when  the  cause  can  be  removed  and 
the  patient  thoroughly  controlled. 

Treatment. — The  avoidance  of  excitement  and  excessive 
mental  work  must  be  enjoined.  An  extended  voyage  may 
effect  a  cure.  In  brain-workers  the  value  of  regular  physical 
exercise  and  frequent  bathing,  followed  by  friction  of  the  skin, 
cannot  be  overestimated.  On  the  other  hand,  the  anaemic  and 
exhausted  may  require  the  "  rest-cure."  The  patient's  experi- 
ence W' ill  assist  in  the  regulation  of  the  diet.  Tonics  like  iron, 
arsenic,  quinine,  and  strychnine  are  often  indicated.  Elec- 
tricity applied  to  the  stomach  has  given  good  results.  Pepsin 
and  mineral  acids  will  be  of  service  only  in  those  cases  in 
which  examination  reveals  a  lack  of  acid  in  the  gastric  juice. 
In  such  cases  Dr.  Pepper  recommends  : — 

^.   Quiuinse  sulph.,  gr.  xxxij  ; 
Strychninee  sulph.,  gr.  ss  ; 
Acid,  hydrochlor.  dil,,  fgij. 
vel      Acid,  phosphor,  dil.,  fsiij  ;• 
Tr.  cardamom,  comp.,  f^ij  ; 
Aqufe,  q.  s.  ad  f3iv. — M.     Filtra. 
Sig. — Teaspoouful  after  meals. 


CATARRHAL   DYSPEPSIA.  41 

CATARRHAL  DYSPEPSIA. 

(Chronic  Gastritis,  Chronic  Gastric  Catarrh.) 

Catarrh  of  the  stomach  is  often  a  primary  condition  result- 
ing from  the  ordinary  causes  of  dyspepsia,  but  its  frequent 
dependence  on  disturbed  circulation  from  heart,  lung,  and  liver 
disease,  or  on  some  constitutional  condition,  such  as  anaemia, 
diabetes,  tuberculosis,  or  Bright's  disease,  should  never  be 
forgotten. 

Pathology. — In  the  early  stages  the  mucous  membrane 
is  ashy-gray  in  color  and  covered  with  tenacious  mucus. 
Ecchymoses  are  often  noted.  Microscopic  examination  re- 
veals degeneration  of  the  glandular  epithelium  and  an  over- 
growth of  the  connective  tissue.  In  advanced  cases  the  walls 
may  be  thin  from  extreme  atrophy  of  the  glandular  structure, 
but  more  often  they  are  thick,  wrinkled,  and  indurated  from 
excessive  overgrowth  of  connective  tissue. 

Characteristic  Symptoms.— The  tongue  is  irregularly 
coated,  the  tip  often  red,  and  the  papillae  enlarged.  The  ap- 
petite is  variable.  After  eating  there  is  weight  and  distress, 
and  often  diffuse  tenderness  on  palpation.  There  are  fre- 
quent eructations  of  gas  and  sour  liquid. 

Nausea  and  vomiting  are  frequently  present ;  the  latter  may 
occur  in  the  morning  on  rising,  and  the  ejected  material  be 
composed  of  the  frothy  mucus  which  has  collected  in  the 
stomach  during  the  night,  or  it  may  occur  some  time  after 
eating,  and  be  composed  of  partially-digested  food  mixed  with 
acids  of  fermentation,  such  as  lactic,  butyric,  and  acetic  acids. 
The  normal  acid,  hydrochloric,  is  nearly  always  diminished 
in  quantity.  The  bowels  are  constipated,  and  the  urine  is 
scanty  and  throws  down  a  heavy  deposit  of  urates  or  phos- 
l)hates.  The  nervous  phenomena  common  to  all  forms  of 
dyspepsia  are  present. 

Protracted  cases,  with  atrophy  of  the  gastric  tubules,  pre- 
sent the  symptoms  of  pernicious  anaemia. 

Diagnosis.  Cancer. — The  age,  haematemesis,  cachexia, 
tumor,  severe  pain,  persistent  vomiting,  tlie  presence  of  lactic 


42  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

acid  after  a  Boas's  test-meal,  the  short  duration,  and  the 
involvement  of  other  organs  will  suggest  cancer. 

Ulcer. — Hsematemesis,  sharp  pain  increased  by  eating, 
vomiting  soon  after  eating,  local  tenderness,  and  abundance 
of  hydrochloric  acid  vrill  suggest  ulcer. 

Care  must  be  taken  to  determine  whether  the  catarrh  is 
primary  or  secondary  to  visceral  disease. 

PeoGoS'osis. — When  not  dependent  on  organic  disease  of 
other  viscera,  the  prognosis  is  good. 

Treatment. — Good  hygienic  conditions.  A  regulated 
diet ;  in  severe  cases  an  absolute  skimmed-milk  diet,  or  par- 
tially-digested foods.  Thick  mucus  and  undigested  food  may 
be  removed  by  the  stomach-tube  when  its  introduction  is  well 
borne.  Pure  or  slightly  alkaline  w^ater  may  be  employed  ; 
but  when  there  is  much  fermentation,  one  per  cent,  of  salicylic 
acid  may  be  added  with  advantage.  Irrigation  should  be 
practised  daily,  or  every  other  day,  preferably  before  break- 
fast, and  the  tube  should  be  kept  in  position  until  the  escap- 
ing fluid  is  quite  clear. 

When  lavage  is  not  well  borne,  the  patient  may  be  directed 
to  sip  before  breakfast  a  half  pint  of  some  hot  alkaline  water, 
such  as  Carlsbad.  This  is  especially  indicated  when  there  is 
constipation. 

Artificial  Carlsbad  salt : — 

^  Sodii  sulph.,  ^v; 
Sodii  bicarb.,  f  ij  ; 
Sodii  chlorid.,  gj.— M.     (Welch.) 
Sig. — 3j  in  a  half  pint  of  water  half  hour  before  breakfast. 

Dilute  hydrochloric  acid  is  nearly  always  indicated,  and  it 
may  be  combined  advantageously  wath  pepsin. 

^L.   Tinct.  nucis  vom.,  f.f  ss  ; 
Acid,  hydrochlor.  dil.,  f^iij ; 
Pepsin.,  3iij ; 

Aquae,  q.  s.  ad.  fsiv. — M. 
Sig. — A  teaspoonful  after  meals. 

The  catarrhal  process  is  often  favorably  influenced  by  sub- 
nitrate  of  bismuth,  or  nitrate  of  silver.  When  there  is  much 
fermentation  and  flatulence,  salicylate  of  strontium  (gr.  v-x), 


GASTEALGIA.  43 

or   subnitrate   of    bismuth  with   some   antiferment    may  be 
employed. 

'^   Salol,  gr.  xl ; 

Bismuth,  subnitrat.,  gss. — M. 
rt.  in  chart.  'No.  xx. 
Sig. — One  powder  half  an  hour  before  meals. 

Instead  of  salol,  creosote  (gtt  J)  may  be  added  to  each  powder. 
Constipation  should  be  relieved  by  diet,  mineral  watei's, 
enemas,  suppositories  of  glycerin  or  gluten,  or  by  mild  laxa- 
tives. x4cid  eructations  and  "  heart-burn"  may  be  relieved  by 
digestants  and  dilute  acids,  taken  immediately  after  meals ;  or 
by  alkalies,  with  or  without  such  antiferments  as  creosote, 
salol,  or  naphthol,  taken  one  or  two  hours  after  meals. 

GASTRALGIA. 

(Gastrodynia,  Neuralgia  of  the  Stomach.) 

Definition. — A  painful  paroxysmal  affection  of  the 
stomach,  unassociated  with  any  organic  lesion. 

Etiology. — Nervous  temperament,  overwork,  anaemia,  and 
dietetic  errors  are  the  predisposing  causes  of  simple  gas- 
tralgia.  A  symptomatic  variety  is  sometimes  observed  in 
gastric  cancer  and  ulcer,  in  locomotor  ataxia,  and  in  nervous 
dyspepsia  with  hyperacidity. 

Symptoms. — Paroxysms  of  severe  pain  in  the  epigastrium, 
usually  radiating  to  the  back,  occurring  when  the  stomach  is 
empty,  and  relieved  by  pressure  and  the  ingestion  of  food  or 
warm  stimulating  drinks. 

Diagnosis.  Gastric  Ulcer. — In  this  disease  the  pain  is  more 
continuous,  is  made  worse  by  eating,  and  is  often  associated 
with  local  tenderness  and  hsematemesis. 

Cancer. — The  age,  history,  continuous  pain  which  is  in- 
creased by  eating,  hsematemesis,  tumor,  cachexia,  anorexia, 
and  absence  of  hydrochloric  acid  will  separate  cancer  from 
gastralgia. 

Angina  Pectoris. — The  radiation  of  the  pain  from  the  heart 
down  the  arm,  fixation  of  the  body,  fear  of  impending  death, 
and  the  associated  symptoms  of  fatty  heart,  such  as  arcus 


44  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

senilis,  rigid  arteries,  and  altered  heart-sounds,  will  separate 
angina  pectoris  from  gastralgia. 

The  lancinating  jpains  of  locomotor  ataxia  sometimes  attack 
the  stomach  and  produce  what  are  termed  gastric  crises. 
These  can  be  distinguished  from  simple  gastralgia  by  the 
absence  of  the  patellar  reflex,  by  the  Argyll-Robertson  pupil, 
the  loss  of  coordination,  and  by  paroxysmal  pains  in  other 
parts  of  the  body. 

Prognosis. — Favorable,  but  duration  indefinite. 

Treatment.  Attack. — Hot  fomentations  should  be  ap- 
])lied  locally,  and  Hoffmann's  anodyne  (5ss),  chloroform  (gtt. 
x),  dilute  hydrocyanic  acid  (gtt.  ij  in  hot  water),  or  the  follow- 
ing mixture  may  be  given  internally  : — 

^   Spt.  vin.  gal. 

Tinct.  opii  campli.,  aa  f^ss  ; 
01.  caryoph.,  gtt.  x.— M. 
Sig. — A  teaspoonful  in  hot  water. 

Or, 

B    Chlorofornii, 

Spt.  ammonise  aromat., 
Spt.  vmi  gallici, 

Tinct.  cardamom,  comp.,  aa  ^ss. — M. 
Sig. — Teaspoonful  every  half  hour. 

In  severe  cases  morphine  will  be  required. 

The  Interval. — Correct  the  hygiene,  regulate  the  diet,  and 
enjoin  rest.  Travel  may  be  extremely  valuable.  Neuras- 
thenia may  require  the  "  rest-cure."  Tonics  are  often  indi- 
cated. When  there  is  hyperacidity,  salicylate  of  bismuth,  car- 
bonate of  soda,  or  aromatic  spirits  of  ammonia,  after  meals,  may 
be  very  serviceable.  Arsenic,  strontium  bromide  (gr.  x— xv),  va- 
lerian, and  dilute  hydrocyanic  acid  are  remedies  of  great  value. 

^   Sodii   arsenat.,    gr.  ss ; 

Ext.  cannabis  ind.,  gr.  iij.— M.    (DaCosta.) 
Ft.  in  pil.  No.  xx. 
Sig. — One,  three  times  daily. 


GASTRIC    ULCER.  45 

GASTRIC  ULCER. 

(Simple  Ulcer,  Perforating  Ulcer.) 

Definition. — An  ulcer  arising  without  obvious  exciting 
cause,  but  which  is  probably  clue  to  the  digestive  action  of 
highly  acid  gastric  juice  on  a  part  of  the  stomach  whose  nutri- 
tion has  been  impaired  by  some  local  disturbance  of  the  cir- 
culation. 

Etiology. — Female  sex,  age  (between  the  fifteenth  and  the 
fortieth  year),  overwork  with  poor  food,  and  anaemia  are  the 
predisposing  causes. 

Pathology. — From  some  local  disturbance  of  the  circula- 
tion— injury,  hemorrhage,  thrombosis,  embolism,  or  spasm  of 
the  vessels — the  part  is  self-digested. 

The  ulcer  is  round  or  oval,  usually  situated  at  the  pylorus, 
on  the  posterior  wall,  near  the  lesser  curvature.  It  has  a 
punched-out  appearance,  is  conical  in  shape,  with  the  apex 
towards  the  peritoneum,  and  is  without  an  inflammatory  areola. 
The  floor  of  the  ulcer  is  usually  smooth,  and  may  be  formed 
by  any  one  of  the  coats  of  the  stomach.  A  series  of  ulcers  is 
not  uncommon,  so  that  more  than  one  may  be  detected. 

Symptoms. — The  general  symptoms  of  dyspepsia,  and  the 
following  characteristic  symptoms :  (1)  Pain.  This  may  be 
severe,  appear  soon  after  eating,  radiate  to  the  back,  and  be 
affected  by  position.  (2)  Hemorrhage.  This  appears  in  one- 
half  of  all  cases  ;  the  bleeding  may  be  profuse,  and  the  blood 
bright  red.  (3)  Localized  tenderness.  This  is  often  detected 
by  palpation  two  or  three  inches  above  the  umbilicus. 
(4)  Vomiting.  This  frequently  occurs  an  hour  or  two  after 
eating  and  at  the  height  of  the  pain.  (5)  Hyper  acidity.  An 
increase  of  HCl  is  almost  invariably  noted  after  a  test-meal, 
unless  gastric  catarrh  be  a  prominent  complication. 

In  some  cases  only  the  symptoms  of  dyspepsia  are  present, 
while  in  others  all  symptoms  may  be  absent,  and  in  the  latter 
hemorrhage  or  perforation  may  be  the  first  indication. 

Events. — (1)  Resolution.  (2)  Death  from  exhaustion, 
hemorrhage,  perforation  and  peritonitis,  or  pyloric  obstruction 
from  cicatricial  contraction. 

Diagnosis.     Cancer. — The  age  (after  forty),  history,  down- 


46  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

ward  course,  short  duration,  extreme  cachexia,  often  out  of 
proportion  to  gastric  symptoms,  tumor,  absence  of  hydro- 
chloric acid,  and  the   presence  of  lactic  acid. 

Gastralgia. — The  pain  usually  appears  when  the  stomach  is 
empty,  and  is  relieved  by  food  and  pressure ;  no  hemorrhage, 
no  local  tenderness ;  other  nervous  phenomena  are  commonly 
present. 

Chronic  Gastritis. — Hemorrhage  rare,  tenderness  diffuse, 
pain  less  marked,  vomiting  less  frequent  and  persistent,  gastric 
acidity  less  than  normal. 

Prognosis. — Guardedly  favorable  ;  such  complications  as 
hemorrhage  or  perforation  may  occur  without  warning,  and 
relapses  from  new  ulcers  are  not  uncommon. 

Treatment. — Absolute  rest  in  bed  and  rectal  feeding. 

Later,  and  in  less  severe  cases  from  the  beginning,  pre- 
digested  milk,  milk  and  lime-water,  buttermilk,  broths,  soft- 
boiled  eggs  and  preparations  of  corn-starch  may  be  given  by 
the  mouth  at  regular  and  frequent  intervals.  This  restricted 
diet  should  be  continued  for  eight  or  ten  weeks,  and  the  return 
to  solid  food  should  be  quite  gradual.  The  more  complete  the 
rest  the  more  rapid  will  be  the  cure.  Lavage  is  contraindi- 
cated,  but  the  stomach  may  be  cleaned  by  the  sipping  of  hot 
alkaline  water  in  the  morning  before  breakfast.  Internally, 
subnitrate  of  bismuth  and  nitrate  of  silver  are  useful  remedies. 

^  Argenti  nitratis,  gr.  v  ; 
Ext.  opii,  gr.  iij. — M. 
rt.  in  pil.  No.  XX. 
Sig.— One  pill  thrice  daily  half  an  hour  before  meals. 

Or, 

^  Bismuth,  subnitrat.,  gvj-^j  ; 

Creosot.,  gtt.  x  ; 

Morphin.  sulph.,  gr.  i-ij. — M. 
Ft.  in  chart.  No.  xx, 
Sig. — One  powder  before  meals. 

Instead  of  morphine,  cocaine  (gr.  ^)  may  be  added  to  each 
powder. 

When  there  is  much  pain  counter-irritation  will  be  of  ser- 
vice. Hemorrhage  will  require  absolute  rest ;  morphine  (gr.  \) 
and  fluid  extract  of  ergot  hypodermically ;  an  ice-bag  to  the 


GASTRIC   CANCER.  47 

stomach,  and  pellets  of  ice  and  tannic  acid  (gr.  v-x)  by  the 
mouth. 

GASTRIC  CANCER. 

Varieties. — (1)  Hard  cancer  (scirrhus).  (2)  Soft  cancer 
(encephaloid).     (3)  Epithelioma.     (4)  Colloid  cancer. 

Etiology. — Male  sex,  age  (after  forty),  heredity,  and  ulcer- 
ation of  the  stomach  are  predisposing  caAities. 

Pathology. — Cancer  of  the  stomach  is  usually  primary  ; 
other  organs  being  involved  secondarily.  The  columnar- 
celled  epithelioma  and  the  encephaloid  are  the  most  common 
forms.  As  the  pylorus  is  the  usual  seat,  gastric  dilatation  is 
a  natural  sequence. 

Symptoms. — The  general  symptoms  of  dyspepsia,  with  the 
following  characteristic  symptoms :  Continued  pain,  often 
tenderness ;  vomiting  of  partially-digested  food ;  absence  of 
free  hydrochloric  acid  in  the  gastric  juice,  and  the  presence  of 
lactic  acid  after  a  flour-soup  test-meal ;  hsematemesis,  the  loss 
beiug  usually  slight,  and  the  blood  so  altered  by  the  gastric 
juice  that  it  presents  a  "  coffee-ground  "  appearance  ;  presence 
of  a  tumor ;  loss  of  flesh  and  strength ;  extreme  anaemia ; 
involvement  of  the  superficial  lymph  glands. 

When  the  pylorus  is  involved,  symptoms  of  gastric  dila- 
tation will  be  added.  These  are  :  Vomiting,  after  the  lapse 
of  several  hours  or  days,  of  large  quantities  of  fermented  ma- 
terial ;  an  increased  area  of  gastric  tympany  on  percussion, 
and  a  reversed  peristaltic  wave  on  inspection. 

Diagnosis. — The  differential  diagnosis  of  gastric  cancer 
from  ulcer,  gastralgia,  and  chronic  gastritis  has  already  been 
discussed. 

Prognosis. — Absolutely  fatal.  The  duration  is  from  six 
months  to  two  years. 

Treatment.  Palliative. — A  liquid  or  semi-liquid  diet. 
Rest.  Hydrochloric  acid  and  pepsin  are  often  required  to  as- 
sist digestion.  When  the  stomach  is  dilated  lavage  may  give 
relief.  Pain  should  be  relieved  by  morphine.  The  other 
symptoms  will  require  the  treatment  indicated  in  gastric  ca- 
tarrh. At  present,  operative  interference  can  scarcely  be 
recommended. 


48 


DISEASES    OF   THE    DIGESTIVE    SYSTEM. 


PYLORIC  OBSTRUCTION  AND  DILATATION 
OF  THE  STOMACH. 

Etiology. — The  causes  of  pyloric  obstruction :  (1)  Pyloric 
tumors,  usually  malignant.  (2)  Tumors  of  adjacent  viscera 
pressing  on  the  pylorus  or  duodenum.  (3)  Cicatrix  of  .an 
ulcer.     (4)  Fibroid  thickening  from  chronic  catarrh. 

Pyloric  obstruction  increases  the  resistance  offered  to  the 
expulsion  of  food,  and  in  its  eflTorts  to  overcome  this,  the  stom- 
ach first  becomes  hypertrophied  and  then  dilated. 

Causes  of  Dilatation  of  the  Stomach  (Gastrectasis). — (1)  Py- 
loric obstruction.  (2)  Relaxation  of  the  walls  from  simple 
atony  or  catarrh.     (3)  Excessive  ingestion  of  food  or  drink. 

Symptoms. — The  general  symptoms  of  dyspepsia,  with  the 
following  characteristic  symptoms,  most  of  which  relate  to  the 
vomit :  Vomiting  occurs  long  after  eating,  sometimes  sev- 
eral hours  or  days ;  the  amount  is  often  excessive,  sometimes 
several  quarts ;  it  is  sour  and  fermented,  and  on  standing  sep- 
arates into  a  sediment  of  undigested  food  and  a  supernatant 
liquid,  which  is  turbid  and  frothy ;  the  ejected  material  is  rich 
in  torulse  and  sarcinse  ventriculi.  There  is  obstinate  constipa- 
tion. 

Fig.  1. 


«> 


«5ft 


«» 


a.  Sarcina  ventriculi.    b.  Torula  cerevisiffi. 


Physical  Signs.  Inspection. — Bulging  over  the  epigas- 
trium ;  in  thin  subjects  the  outline  of  the  stomach  may  be 
visible.     Sometimes  a  peristaltic  wave  is  detected. 

Palpation,-^A  splashing  fremitus. 


GASTROPTOSIS    AND    ENTEROPTOSIS.  .  49 

Percussion. — Increased  area  of  gastric  tympany.  Artificial 
distention  of  the  stomach  with  carbonic-acid  gas,  evolved  by 
the  administration  of  bicarbonate  of  soda  and  tartaric  acid,  is 
rarely  necessary,  and  is  sometimes  harmful. 

Auscultation. — Splashing  sounds.  These  are  often  audible 
at  some  distance,  and  hence  are  a  frequent  source  of  annoy- 
ance to  the  patient. 

Mensuration. — Normally  an  oesophageal  sound  may  be  in- 
serted a  distance  of  60  ctm.  from  the  teeth  ;  in  dilatation  it 
aiay  be  inserted  65  or  70  ctm. 

Prognosis. — Depends  on  the  cause ;  it  should  always  be 
guarded.  It  is  more  favorable  in  dilatation  without  obstruc- 
tion. In  cicatricial  contraction  operative  interference  has  given 
fair  results.    In  cancer  the  prognosis  is  absolutely  unfavorable. 

Treatment. — The  diet  should  be  light  and  nutritious,  not 
bulky,  and  should  be  given  in  small  amounts  at  frequent  in- 
tervals. Lavage  practised  two  or  three  times  weekly  is  of 
great  value.  In  cancer  the  treatment  is  palliative.  In  fibroid 
thickening  and  cicatricial  constriction,  dilatation  of  the  pylorus 
(Loreta's  operation)  or  the  establishment  of  a  gastro-duodenal 
fistula  may  be  suggested.  These  operations  have  been  fairly 
successful.  In  simple  dilatation,  treat  the  catarrh  and  apply 
massage  and  electricity ;  the  latter  may  be  applied  to  the  in- 
terior of  the  stomach  by  means  of  a  bipolar  stomachal  elec- 
trode. (Rockwell.)  Tonics,  especially  strychnine,  are  often 
valuable  adjuncts.  An  abdominal  support  often  relieves  some 
of  the  distressing  symptoms. 

GASTROPTOSIS  AND  ENTEROPTOSIS. 

(Glenard's  Disease.) 

Definition. — A  prolapse  or  downward  displacement  of 
the  stomach  and  intestines. 

Etiology. — The  condition  is  most  common  in  women. 
Tight-lacing,  muscular  strain,  repeated  pregnancies,  rapid 
emaciation,  and  malnutrition  are  predisposing  causes. 

Pathology. — Gastroptosis  and  enteroptosis  are  frequently 
coexistent.  Ptosis  of  the  kidney,  spleen,  or  liver  may  also  be 
present.  Both  large  and  small  intestines  may  be  affected, 
4 


50  DISEASES    OF    THE    DIGESTIVE   SYSTEM. 

but  the  condition  is  more  frequently  observed  in  the  colon, 
especially  the  transverse  portion,  which  may  be  found  elon- 
gated and  tortuous,  and  occupying  a  position  immediately 
above  the  symphysis  pubis. 

Symptoms. — When  marked,  ptosis  of  the  viscera  gives  rise 
to  nervous  dyspepsia,  flatulence,  constipation,  colicky  pains, 
and  the  phenomena  of  neurasthenia.  The  position  of  the  stom- 
ach and  colon  may  be  determined  by  inflation  with  air  or  gas. 

Diagnosis. — After  inflation  the  diagnosis  between  gastrop- 
tosis  and  gastrectasis  can  usually  be  made  without  difficulty. 

Treatment. — The  chief  objects  are  to  remove  the  cause 
and  to  improve  nutrition.  The  application  of  massage  and 
electricity  to  the  abdominal  walls  may  prove  useful.  A  sup- 
porting bandage  gives  some  relief. 

H^MATEMESIS. 

(Gastrorrhagia. ) 

Etiology. — (1)  Traumatism.  (2)  Acute  gastritis.  (3) 
Obstruction  to  the  circulation,  as  in  chronic  heart,  lung,  and 
liver  disease.  (4)  Vicarious  menstruation.  (5)  Blood  dys- 
crasia,  as  in  scurvy,  infectious  fevers,  grave  ansemia,  purpura, 
etc.  (6)  Rupture  of  an  aneurism.  (7)  Gastric  ulcer.  (8) 
Gastric  cancer.  (9)  Swallowing  of  blood  from  nose,  mouth, 
or  throat.     (10)  Hysteria. 

Diagnosis.  Hoematem^sis. — Blood  is  often  clotted  and 
mixed  Math  food,  is  acid  in  reaction;  the  subsequent  stools 
may  be  tarry,  and  the  associated  symptoms  usually  point  to 
the  stomach  or  adjacent  organs. 

Haemoptysis. — Blood  is  red,  frothy,  and  alkaline  in  reaction, 
the  subsequent  expectorations  are  streaked  with  blood,  and 
physical  signs  usually  indicate  the  cause. 

Treatment. — Absolute  rest ;  abstinence  from  food  by  the 
mouth  ;  an  ice-bag  to  the  stomach.  Pellets  of  ice  may  be 
sucked.  Tannic  acid  (gr.  v-x)  by  the  mouth,  and  fluid  ex- 
tract of  ergot  (sss)  with  morphine  (gr.  \)  hypodermically.  ^  If 
the  hemorrhage  has  been  profuse,  use  subcutaneous  injections 
of  weak  saline  solutions ;  give  iron  by  the  mouth,  and  advise 
the  use  of  salty  broths. 


CONSTIPATION.  51 

CONSTIPATION. 

Definition. — An  unnatural  retention  of  fecal  matter. 

Etiology. — (1)  Many  acute  and  chronic  diseases  which 
lessen  peristalsis  and  secretion,  as  most  chronic  visceral  dis- 
eases, all  nervous  diseases,  anaemia,  and  the  infectious  fevers, 
except  typhoid.  (2)  Sedentary  habits.  (3)  Concentrated 
food.  (4)  Certain  drugs,  as  lead  and  opium  ;  it  is  an  after- 
effect of  strong  purgatives.  (5)  Atony  of  the  intestinal  wall, 
common  in  the  old  and  debilitated.     (6)  Stricture. 

Symptoms. — Infrequent  stools,  dyspepsia,  fetid  breath, 
headache,  vertigo,  lassitude,  anaemia. 

Results. — In  aggravated  cases  :  dyspepsia,  diarrhcea  from 
irritation,  fecal  accumulation,  hemorrhoids,  fissure,  fistula, 
prolapse  of  the  rectum. 

Treatment. — A  regular  time  for  defecation  should  be  ob- 
served. Systematic  exercise,  abdominal  massage,  and  elec- 
tricity are  valuable  aids.  Encourage  the  use  of  water,  bran- 
bread,  green  vegetables,  and  stewed  fruits.  In  mild  cases  a 
glass  of  water  or  an  orange  before  breakfast  will  suffice.  Ene- 
mata  of  water,  or  glycerine  (3j-3iv),  or  suppositories  of  glyc- 
erine or  of  gluten  may  be  required. 

Mineral  waters,  like  Fried  rich  shall  or  Hunyadi,  often  give 
relief. 

In  obstinate  cases  mild  laxatives  must  be  employed  ;  cascara 
sagrada  is  one  of  the  best.  The  dose  of  the  extract  is  one  to 
three  grains  ;  of  the  fluid  extract,  half  to  a  fluid  drachm. 

Sometimes  combinations  are  desirable. 

^  Aloin,  gr.  iv  ; 

Styrchninse,  gr.  ^  ; 

Ext.  belladonnse, 

Pulv.  ipecac,  aa  gr.ij. — M. 
Ft.  in  pil.  No.  xx. 
Sig. — One  or  two  as  required. 

Or, 

^  Pulv.  rhei,  gr.  xl ; 

Pulv.  aloes,  gr.  xx  ; 

Ext.  physostig.,  gr.  iij  ; 

Ol.  caryophylli,  gtt.  iij. — M 
Pt.  in  pil.  No.  XX. 
Sig. — One  or  two  as  required. 


52  DISEASES    OF    THE    DIGESTIVE   SYSTEM. 

rNTESTENAl,  COLIC. 

(Enter algia,  Tormina.) 

Definition. — A  painful  spasmodic  affection  of  the  intes- 
tines. 

Etiology. — It  usually  results  from  irritating  food,  flatu- 
lence, or  fecal  accumulation.  It  is  sometimes  of  rheumatic  or 
gouty  origin.  It  may  be  reflex  from  disease  of  the  ovaries, 
uterus,  liver,  spine,  etc.  It  is  also  a  symptom  of  lead-poison- 
ing, intestinal  inflammation,  and  intestinal  obstruction.  It  may 
be  a  crisis  of  locomotor  ataxia. 

Symptoms. — Paroxysms  of  severe  pain  of  a  twisting  char- 
acter, centering  around  the  umbilicus,  and  relieved  by  pressure. 
The  abdomen  is  usually  distended.  Severe  attacks  may  lead 
to  incipient  collapse,  indicated  by  cold  sweats,  pinched  features, 
feeble  pulse,  and  vomiting.  The  attack  lasts  from  a  few 
minutes  to  several  hours,  and  usually  ends  by  a  discharge  of 
flatus. 

Diagnosis.  Lead  CoUg. — History,  blue  line  on  the  gums, 
retracted  abdominal  walls,  and  lead  in  the  urine. 

Biliai'y  Colic. — Pain  radiating  from  the  liver  to  the  back 
and  right  shoulder,  jaundice,  and  calculus  in  the  stool. 

Renal  Colic. — Pain  radiating  down  the  ureter  to  penis  and 
testicle,  blood,  mucus,  pus,  or  calculi,  in  the  urine. 

Abdominal  Aneurism. — Tumor,  pulsation,  bruit. 

Peogn  osis. — Favorable. 

Treatment. — Apply  hot  applications  to  abdomen,  and 
administer  morphine  (gr.  \)  with  sulphate  of  atropine  (gr. 
i^Q^)  hypodermically.  Subsequently  employ  a  saline  or  mer- 
curial purge.     In  the  interval  treat  the  causal  condition. 

Lead  Colic. — Use  magnesium  sulphate  as  a  cathartic,  and 
potassium  iodide  (gr.  v-x,  thrice  daily)  to  eliminate  the  lead. 

DIABRH(EA. 

Definition. — A  condition  in  which  the  stools  are  too  fre- 
quent or  too  liquid.  Like  dyspepsia,  it  is  a  symptom  of  many 
pathological  conditions. 

Etiology. — (1)   It  results  from  inflammation  of  the  in- 


INTESTINAL    CATARRH.  53 

testines,  as  enteritis,  entero-colitis,  dysentery.  (Inflammatory 
diarrhoea.)  (2)  It  is  a  symptom  of  certain  infectious  diseases, 
as  typhoid  fever,  cholera.  (Symptomatic  diarrhoea.)  (3)  It  is 
produced  by  certain  drugs,  as  laxatives  and  purgatives.  (4)  It 
may  be  an  expression  of  cachexia  occurring  as  a  final  symptom 
in  cancer,  diabetes,  and  chronic  Bright's  disease.  (Colliqua- 
tive diarrhoea.)  (5)  It  may  be  a  closing  symptom  in  acute 
febrile  diseases  which  end  by  crisis,  as  typhus  fever,  re- 
mittent fever.  (Critical  diarrhoea.)  6.  It  may  result  from 
nervous  excitement  or  sensational  disturbance.  This  is  prob- 
ably due  to  a  vaso-motor  paresis  of  the  intestinal  vessels  (an 
intestinal  "blush"),  and  the  subsequent  outpouring  of  serum. 
(Nervous  diarrhoea.) 

INTESTINAL  CATAKRH. 

(Diarrhoea,  Catarrhal  Enteritis.) 

Etiology. — Warm  weather,  childhood,  and  bad  hygiene 
are  general  predisposing  causes.  It  is  usually  excited  by  a 
sudden  change  in  temperature,  or  by  irritating  products  in  the 
intestinal  canal.  Ptomaines  produced  by  the  decomposition 
of  food  are  the  most  common  excitants.  It  may  be  induced 
by  corrosive  poisons,  as  antimony,  arsenic,  mercury. 

Pathology. — The  mucous  membrane,  especially  of  the 
upper  bowel,  is  injected,  swollen,  and  covered  with  tenacious 
mucus.  The  solitary  and  agminated  glands  are  enlarged,  and 
are  sometimes  the  seat  of  pinhead  ulcerations. 

In  chronic  enteritis  the  mucous  membrane  is  often  thickened 
from  an  overgrowth  of  connective  tissue,  but  in  some  instances 
it  is  unusually  thin  from  atrophy  of  the  coats  and  destruction 
of  the  glands. 

Symptoms.  Acute  Enteritis. — Frequent  stools,  three  to 
twelve  or  more  a  day,  of  a  yellowish  or  greenish  color,  and 
containing  undigested  food ;  colicky  pains,  with  rumbling 
noises  (borborygmi) ;  and  slight  fever  with  its  attending  phe- 
nomena. 

Chronic  Enteritis. — Frequent  liquiol  stools  which  vary  in 
color  and  character  according  to  the  seat  of  catarrh ;  much 


54  DISEASES    OF   THE    DIGESTIVE   SYSTEM. 

undigested  food  (lientery)  indicates  involvement  of  the  upper 
bowel ;  and  much  mucus,  involvement  of  the  lower  bowel. 
The  excessive  drain  leads  to  aneemia,  emaciation,  and  weak- 
ness. 

Membranous  Enteritis. — This  term  has  been  applied  to  two 
conditions  :  (1)  A  true  croupous  enteritis,  which  is  associated 
with  the  formation  of  a  false  membrane,  and  which  is  seen  in 
cachectic  states,  in  acute  infectious  diseases,  and  as  a  result  of 
mineral  poisoning.  (2)  Mucous  colic,  or  mucous  colitis,  a 
chronic  form  of  colitis,  usually  occurring  in  women  of  a 
marked  nervous  temperament,  and  characterized  by  paroxysms 
of  severe  pain,  and  the  discharge  of  gray  translucent  casts 
which,  however,  are  not  membranous,  but  mucoid  in  character. 

Diagnosis.  Dysentery. — The  marked  prostration  and  te- 
nesmus, and  the  small,  mucous  and  bloody  discharges  will 
indicate  dysentery. 

Entero-colitis. — In  this  affection  there  is  more  fever,  the 
prostration  is  greater,  and  the  stools  contain  considerable 
mucus,  and  even  blood. 

Typhoid  Fever. — The  gradual  onset,  nose-bleed,  splenic 
enlargement,  characteristic  temperature  curve,  and  eruption 
will  lead  to  the  recognition  of  typhoid  fever. 

Peognosis. — Good,  under  favorable  conditions. 

Treatment. — In  adults. — Rest.  Liquid  diet.  When 
there  is  retention  of  irritating  material,  indicated  by  the  his- 
tory, sharp  pain,  abdominal  distention,  and  small  stools,  ad- 
minister a  laxative,  as  calomel,  or  castor  oil  with  laudanum. 

1^  Hydrarg.  chlor.  mit.,  gr.  ij  ; 
Sodii  bicarb.,  gj. — M. 
Ft.  m  chart.  Ko.  xii. 
Sig. — One  every  hour  until  five  or  six  have  been  taken. 

Or— 

'^  01.  ricini, 

Syr.  rhei  arotnat.,  aa  f^ss  ; 
Tinct.  opii,  gtt.  x-xx. — M. 
Eepeat,  if  necessary. 

When  the  bowel  has  been  thoroughly  emptied,  opium,  as- 
tringents, and  intestinal  antiseptics  will  be  required.     Thus  : — 


INTESTINAL  CATARRH.  55 

^  Bismuth,  subnit.,  ^ss; 

Morphia,  sulph.,  gr.  j  ; 

Creosoti,  gtt.  vj. — M. 
rt,  in  chart.  No.  xii. 
Sig, — One  every  two  hours. 

Or— 

^   Bismuth,  subnit., 

Crette  preepar.,  aa  jij  ; 
Tinct.  opii  camph.,  f^iss  ; 
Tinct.  kino,  f^ij  ; 
Pulv.  acacise,  q.s  ; 

Aquse  cinnamomi,  q.s,  ad.  f^vj. — M, 
Sig. — A  tablespoonful  every  three  hours. 

Chronic  Diarrhoea. — Liquid  diet.  Rest.  Intestinal  antisep- 
tics (salicylate  of  bismuth,  uaphthaliu,  salol),  and  opium  with 
mineral  astringents. 

Diarrhcea  in  Children. — Absolute  cleanliness.  Frequent 
bathing.  A  change  of  air,  if  possible.  If  the  child  is  bottle- 
fed,  the  milk  must  be  sterilized  and  given  at  regular  intervals. 

If  the  diarrhoea  still  persists,  milk  should  be  abandoned,  and 
the  child  fed  for  a  few  days  on  egg  alburnin,  beef  juice,  or 
beef  peptonoids.  A  flannel  binder  should  be  applied  to  the 
abdomen.  The  bowels  should  be  emptied  with  castor  oil  (5j) 
to  which  may  be  added  a  few  drops  of  paregoric  ;  or — 

^   Hydrarg.  chlor.  mit,,  gr,  j  ; 

Bismuth,  salicylat,,  gr.  xxxvj  ; 

Pulv,  zingiber.,  gr.  xij. — M. 
rt.  in  chart.  No.  xii. 
Sig. — One  every  hour. 

After  this  has  operated,  astringents  may  be  employed. 

^   Sodii  salicylat.,  gr.  xij  ; 

Bismuth,  subnit.,  gi*.  xxxvi ; 

Pulv.  aromat.,  gr.  vj, — M. 
Ft,  in  chart,  No.  xii, 
Sig. — One  every  two  hours, 

^   Sodii  bicarb, .  ^ss  ; 

Syr,  rhei  aromat.,  f^ss; 
Aq,  menth,  pip.,  fgijss, — M,    (Starr,) 
Sig. — 3j  every  two  hours. 


56  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

Or— 

R     Sodii  salicylat.,  gr.  xxiv ; 
Bismuth,  subnit.,  3ij  ; 
Tinct.  opii  camph.,  f^iij ; 
Mist,  ci'etge,  f^iss ; 
Aquse  cinnamomi,  q.s.  ad  f^iij. — M. 
Sig. — One  to  two  teaspoonfuls  every  two  liours. 

ACUTE  ENTERO-COLITIS. 

(Follicular  Enteritis.) 

Definition. — An  inflammation  involving  mainly  the 
ileum  and  colon,  and  affecting  especially  the  lymphatic  glands. 

Etiology. — Warm  weather,  childhood,  improper  food,  and 
bad  hygiene  are  predisposing  factors. 

It  may  be  a  sequel  of  catarrhal  enteritis  or  cholera  infantum. 

Pathology. — The  mucous  membrane  is  red,  swollen,  and 
cedematous.  The  solitary  and  agminated  glands  are  swollen 
and  often  ulcerated. 

Symptoms. — Frequent  stools,  at  first  yellow,  later  green, 
and  mixed  with  curd,  mucus,  blood,  and  sometimes  material 
resembling  chopped  spinach.  The  dejecta  are  neutral  or  acid 
in  reaction.  There  is  moderate  fever  102°-103°,  with  its 
usual  phenomena.  The  abdomen  is  distended,  and  tender 
along  the  colon.  Vomiting  is  rarely  persistent.  The  child 
grows  pale,  wastes,  and  assumes  a  senile  appearance.  Death 
may  be  preceded  by  coma  and  convulsions.  (Spurious  hydro- 
cephalus.) 

Diagnosis. — Reference  has  already  been  made  to  its  sepa- 
ration from  catarrhal  enteritis. 

Cholera  infantum  may  be  recognized  by  the  abrupt  onset, 
very  high  fever,  incessant  vomiting,  serous  purging,  and  early 
collapse. 

Prognosis. — Grave,  yet  recoveries  follow  under  favorable 
conditions. 

Treatment. — Much  the  same  as  in  catarrhal  enteritis. 
Stimulants  are  frequently  required.  Weak  stupes  or  spice 
poultices  should  be  ap]ilied  to  the  abdomen.  Topical  treat- 
ment should  not  be  neglected.     The  bowel  should  be  irrigated 


CHOLERA    INFANTUM.  67 

once  a  day  with  a  pint  or  more  of  cold  Avater  containing  one 
per  cent,  of  sodium  benzoate  or  salicylic  acid.  The  irrigation 
may  be  followed  by  the  injection  of  an  ounce  of  water  con- 
taining nitrate  of  silver  (gr.  ^1)  and  perhaps  laudanum  (gtt. 

jj-iij)- 

CHOLERA  IKFANTUM. 

Definition. — An  acute  disease  of  childhood,  characterized 
by  high  fever,  vomiting,  purging,  and  collapse,  and  dependent 
upon  an  inflammation  of  the  gastro-intestinal  tract,  and  some 
disturbance  of  the  sympathetic  ganglia. 

Etiology. — Hot  weather,  faulty  feeding,  dentition,  and  bad 
hygiene  are  predisposing  factors. 

Pathology. — The  mucous  membrane  of  the  stomach  and 
intestines  is  red,  swollen,  and  oedematous  ;  the  glands  are  en- 
larged or  ulcerated.  The  profuse  serous  discharges  and  rapid 
collapse  must  be  due,  in  part,  to  some  disturbance  of  the  sym- 
pathetic nerves. 

Symptoms. — The  onset  may  be  gradual  or  abrupt.  Diar- 
rhoea is  usually  the  initial  symptom  ;  the  stools  are  thin  and 
serous,  have  a  musty  odor  and  an  alkaline  reaction.  Vomit- 
ing soon  develops,  and  the  gastric  irritability  is  so  great  that 
everything  is  rejected.  Thirst  is  intense,  the  temperature  is 
very  high  (105°  to  108°);  the  pulse  is  rapid  and  feeble;  the 
urine  is  scanty.  Collapse  follows,  and  is  indicated  by  the 
pinched  features,  hollow  eyes,  sunken  fontanel les,  and  cold 
surface.  Even  at  this  time  a  reaction  may  set  in,  but  more 
commonly  death  results  from  exhaustion.  The  end  may  be 
characterized  by  the  symptoms  of  spurious  hydrocephalus — 
restlessness,  convulsions,  irregular  pupils,  and  coma ;  and  as 
these  phenomena  are  unassociated  with  any  cerebral  lesion 
they  are  probably  toxsemic. 

Diagnosis.  Enter o-colitis. — Gradual  onset,  moderate  fever, 
vomiting  less  marked,  stools  more  mucous  than  serous  and 
neutral  or  acid  in  reaction,  pulse  not  so  rapid,  and  no  tendency 
to  sudden  collapse. 

Prognosis.  —  Grave.     Under  conditions  most  propitious, 


58  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

death  may  result  in  from  one  to  three  days;  on  the  other 
hand,  no  aspect  is  too  serious  to  admit  of  recovery.  Entero- 
colitis is  a  common  sequel. 

Treatment. — If  possible,  the  child  should  be  removed  to 
the  country  or  seashore.  It  should  be  kept  in  the  open  air. 
Cleanliness  is  essential  to  success,  and  frequent  bathing  with 
cool  water  is  desirable.  A  spice-plaster  or  a  weak  stupe  should 
be  applied  to  the  abdomen. 

The  nourishment  should  consist  of  barley-water,  beef-juice, 
wine-whey,  chicken-broth,  or  frozen  blocks  of  beef-tea ;  these 
should  be  given  in  small  quantities  at  frequent  intervals. 
Pellets  of  ice  should  be  given  to  allay  thirst.  A  few  drops  of 
brandy  or  of  aromatic  spirits  of  ammonia  may  be  required  at 
frequent  intervals  to  combat  prostration. 

To  arrest  vomiting  use  calomel  (gr.  jL-)?  subnitrate  of  bismuth 
(gj*.  iij-v),  or  nitrate  of  silver. 

'^   Argenti  nitrat.,  gr.  ss-j  ; 
Syr.  acaciae,  f^  j  ; 
Aqute,  f^ij. — M. 
Sig. — A  teaspoonful  every  two  hours. 

For  the  diarrhoea,  laudanum  (gtt.  ij-iij)  with  starch-water 
(3j)  may  be  given  every  three  or  four  hours  by  the  rectum. 
Or  the  following  may  be  given  by  the  mouth  : — 

!^   Liquor,  morph.  sulph.,    f^j  ; 
Acid,  sulphur,  aroniat.,  TTl  xxiv  ; 
EUx.  curacose,    f^ss; 
Aquse,  q.  s.  ad.  f^iij. — M. 
Sig.— One  teaspoonful  every  two  hours  for  a  child  six  months  old. 

When  vomiting  and  purging  seem  uncontrollable,  morphine 
fe^-  T2"o  ^^  1  o"?)  hypodermically  may  be  very  useful. 

Irrigation  of  the  stomach  and  bowel  with  warm  water  has 
been  highly  recommended,  and  though  heroic  sometimes  gives 
brilliant  results.  In  collapse,  use  a  hot  bath  to  which  a  little 
mustard  or  red  pepper  has  been  added ;  then  place  the  child 
in  a  horizontal  position,  cover  with  warm  blankets,  and  ad- 
minister stimulants  freely. 


DYSENTERY.  59 

DYSENTERY. 

(Bloody  Flux.) 

Definition. — An  inflammatory  disease  of  the  colon,  char- 
acterized by  tenesmus,  and  the  passage  of  small,  mucous,  and 
blood-streaked  stools. 

Etiology. — (1)  Warm  climates  and  warm  weather;  (2) 
bad  hygience ;  (3)  ingestion  of  irritating  food  ;  (4)  exposure 
to  cold  and  wet ;  (5)  cachectic  states  (scurvy,  gangrenous 
stomatitis,  and  Bright's  disease)  are  predisposing  factors,  and 
alone  may  produce  simple  dysentery ;  but  the  tropical  form 
(also  occurs  in  cold  climates)  seems  to  be  excited  by  an  animal 
parasite,  the  amoeba  coli. 

The  disease  frequently  occurs  in  epidemic  form. 

Varieties. — (1)  Acute  catarrhal  or  sporadic  dysentery. 
(2)  Amoebic  or  tropical  dysentery.  (3)  Malignant  or  diph- 
theritic dysentery.     (4)  Chronic  dysentery. 

Pathology.  Catarrhal  Dysentery. — Mucous  membrane  of 
the  colon  is  red,  swollen,  oedematous,  and  in  some  cases  ulcer- 
ated. 

Fia:.  2. 


Amoeba  coli. 


Amoebic  Dysentery. — The  mucous  membrane  is  swollen  from 
oedema  and  cellular  infiltration.  The  latter  causes  superficial 
necrosis,  and  the  formation  of  irregular  ulcers  which  more  or 
less  undermine  the  surrounding  mucosa.  The  amoebae  are 
found  in  the  floor  of  the  ulcers,  and  in  the  surrounding  tissue. 
In  some  cases,  false  membrane  and  sloughs  appear.  Abscess 
of  the  liver  is  a  common  complication. 

Diphtheritie  Dysentery. — The  mucous  membrane  is  intensely 
swollen,  and  covered  with  a  false  membrane,  which  results 
from  coagulation-necrosis.  The  separation  of  the  membrane 
is  followed  by  ulceration  and  sloughing. 


60  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

Chronic  Dysentery. — May  be  simple  or  amoebic.  The  coats 
are  greatly  thickened  and  ulcers  are  usually  found.  Cicatri- 
cial contractions  sometimes  follow. 

Symptoms.  Acute  Catarrhal  Dysentery. — Moderate  fever 
and  its  associated  phenomena,  prostration,  colic,  abdominal 
tenderness,  tenesmus  (fulness  in  the  rectum  with  a  constant 
desire  to  defecate)  with  small,  mucous,  and  bloody  stools. 

Amoebic  Dysentery. — May  begin  as  an  acute  or  chronic  dis- 
ease. The  symptoms  are  similar  to  catarrhal  dysentery,  but 
the  disease  is  more  protracted,  and  often  marked  by  intermis- 
sions and  exacerbations ;  the  stools  are  more  fluid  and  contain 
the  amoeba  coli,  and  abscess  of  the  liver  is  a  more  frequent 
complication  than  in  other  forms  of  dysentery. 

Malignant  or  DijMheritic  Dysentery.  —  To  the  ordinary 
symptoms  the  following  typhoid  phenomena  are  added  :  Mut- 
tering delirium,  stupor,  subsultus,  carphologia,  and  a  brown, 
fissured  tongue.  The  stools  also  contain  false  membrane  and 
sloughs. 

Chronic  Dysentery. — Great  loss  of  flesh  and  strength ;  ex- 
treme ansemia;  the  discharges  contain  cousiderable  mucus 
and  at  times  are  bloody.  Tenesmus  and  pain  may  be  absent. 
The  history  of  the  initial  symptoms  will  establish  the  diagnosis. 

Diagnosis.  Diarrhoea.  —  Absence  of  tenesmus  and  of 
mucoid  and  bloody  stools. 

Intussusception. — Late  development  of  fever,  stools  more 
bloody  than  mucoid,  the  presence  of  a  "  sausage-like"  tumor 
and  persistent  vomiting. 

Peogjstosis. — In  acute  catarrhal  dysentery  the  prognosis  is 
good  ;  recovery  usually  follows  in  from  a  few  days  to  a  week. 
In  amoebic  dysentery  the  prognosis  should  be  guardedly 
favorable;  relapses  are  common,  and  abscess  of  the  liver  is 
liable  to  occur.  The  duration  in  favorable  cases  is  from  six 
to  eight  weeks.  Malignant  dysentery  is  always  a  grave  dis- 
ease and  often  proves  fatal. 

Complications. — Peritonitis  from  extension  or  perforation, 
hepatic  abscess,  stricture,  and  paralysis  from  neuritis. 

Hepatic  abscess  may  be  of  amoebic  or  bacterial  origin, 
although  the  former  is  the  more  common. 

Treatment.  Acute  Dysentery. — Absolute  rest  and  the  en- 
forced use  of  the  bed-pan.     Liquid  diet.     Apply  externally 


DYSENTERY.  61 

hot  fomentations,  niustard-poultices  or  leeches.  A  mild  laxa- 
tive is  indicated  in  the  beginning;  sulphate  of  magnesium  (gij), 
or  castor-oil  and  laudanum  might  be  selected,  and  either  may 
be  repeated  until  the  eifect  is  produced. 

Internally,  bismuth  is  a  valuable  remedy ;  salicylate  of  bis- 
muth (gr.  x)  or  subnitrate  of  bismuth  with  salol  or  creosote 
may  be  employed. 

]^  Morplun.-sulph.,  gr.  j  ; 

Bismuth,  subnit.,  ^ij  ; 

Creosoti,  gtt.  vj.— >M. 
Ft.  in  pulv.  'No.  xii. 
Sig. — One  every  hour  or  two. 

Or, 

^  Salol,  3j  ; 

Bismuth,  subnit., 

Sodii  bicarb.,  aa  gr.  c— M. 
In  twenty  capsules.  (DuJARDiN-BEAu:yiETZ.) 

Sig. — One  three  or  four  times  daily. 

Musser  recommends — 

^   Quininse  sulph.,  gr.  xl ; 

Ext.  opii,  gr.  v  ; 

Mass.  hydrarg.,  gr.  x. — M. 
Ft.  in  pil.  ISTo.  xx. 
Sig. — One  or  two  every  two  or  three  hours. 

In  some  cases,  particularly  in  those  associated  with  bilious 
symptoms,  ipecacuanha,  in  large  doses  (gr.  xx-xxx,  repeated 
every  three  or  four  hours),  is  very  serviceable.  To  prevent 
emesis,  twenty  drops  of  laudanum  should  be  given  half  an  hour 
before  the  administration  of  the  ipecacuanha.  Topical  treat- 
ment should  never  be  omitted.  In  mild  cases  opium  supposi- 
tories will  prove  very  beneficial ;  in  severe  cases  enemata  of 
thin  starch-water  with  laudanum  (gtt.  xx-xxx)  should  be 
substituted  for  the  suppositories.  H.  C.  Wood  highly  recom- 
mends the  use  of  ice  suppositories,  one  every  two  to  five 
minutes  for  half  an  hour,  followed  by  suppositories  of  ergot 
and  iodoform  : — 

I^   Ext.  ergot.,  gr.  Ixxij  ; 

Iodoform.,  gss  ; 

01.  theobrom.,  q,  s. — M. 
Ft.  in  suppos.  No.  vi. 
Sig. — One  every  two  hours  until  four  or  five  have  been  taken. 


62  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

Astringent  injections  of  nitrate  of  silver  or  lead  acetate  should 
be  reserved  for  subacute  or  chronic  cases. 

Injections  of  warm  solutions  of  quinine  (50W  ^^  riV'o)  I'^'Ve 
recently  been  employed  in  amoebic  dysentery  with  advantage. 
(Osier.)  Creolin  (a  drachm  to  the  pint)  has  given  good  results 
in  similar  cases. 

In  malignant  dysentery,  quinine,  alcohol,  and  turpentine 
are  indicated. 

Chronic  Dysentery. — Rest ;  liquid  diet ;  intestinal  antisep- 
tics (salicylate  of  bismuth),,  and  copious  injections  of  nitrate  of 
silver  in  aqueous  solution,  as  recommended  by  Wood.  Be^in 
with  one  or  two  pints  (gr.  xx  to  the  pint),  and  inject  through 
a  tube  pushed  far  up  the  bowel ;  later,  increase  to  three  or 
four  pints  (gr.  xxx  to  the  pint).  The  injections  may  be  em- 
ployed once  or  twice  weekly. 

CHOLERA  MORBUS. 

(English    Cholera,  Cholera  Nostras.) 

Definition. — An  acute,  sporadic  disease,  resembling  Asiatic 
cholera,  but  not  excited  by  the  comma  bacillus  of  Koch, 

Etiology. — The  summer  season  predisposes,  and  irritating 
food,  as  unripe  fruit,  and  a  sudden  change  of  temperature  are 
the  usual  exciting  causes.  A  ptomaine  or  a  special  bacillus 
probably  induces  the  disease. 

Symptoms. — Intense  cramps  in  the  stomach,  vomiting  and 
purging  of  bilious  material,  moderate  fever,  and  great  pros- 
tration. In  severe  cases  the  discharges  become  serous,  and 
symptoms  of  collapse  develop. 

Diagnosis.  Asiatic  Cholera. — No  history  of  dietetic  indis- 
cretion ;  a  direct  etiological  relation  with  another  case  ;  "  rice- 
water"  discharges;  severe  cramps  in  the  legs,  and  presence 
of  cholera  spirilla. 

Corrosive  Prisons  (as  antimony). — History ;  the  vomiting 
precedes  purging;  burning  pain  in  oesophagus  and  rectum; 
and  bloody  mucous  discharges. 

Prognosis. — Favorable ;  death  rarely  occurs.  Duration, 
twenty-four  to  forty-eight  hours. 

Treatment, — Hot  applications  to  the  abdomen.  Morphine 
(gr.  J)  with  atropine  (gr.  yo^),  hypodermically,  repeated  if 


APPENDICITIS.  63 

necessary.  When  the  pain  is  less  severe  opium  may  be  given 
by  the  mouth  or  rectum.  Ice  is  soothing  and  relieves  the 
thirst.  When  vomiting  is  the  most  troublesome  symptom  the 
following  will  be  beneficial : — 

^.  Morph.  sulph. ,  gr.  j  ; 

Creosoti,  gtt.  vj  ; 

Bismuth,  subnit.,  ^ij. — M. 
rt.  in  chart.  No.  xii. 
Sig.— One  every  hour. 

Prostration  will  require  stimulants,  like  aromatic  spirits  of 
ammonia  or  brandy. 

In  many  cases  the  following  mixture  will  be  all  that  is 
required : — 

^   Tinct.  opii  camph.,  f^ss  ; 
Spt.  ammon.  aromat,,  fgj  ; 
Magnesise,  3j ; 
Aq.  menth.  piperitse,  q.  s.  ad.  f.^iv. — M. 

(Hartshorne.) 
Sig. — A  teaspoonful  every  twenty  minutes. 

APPENDICITIS. 

(Typhlitis,  Perityphlitis.) 

Definition. — An  inflammation  of  the  ajjpendix  vermi- 
formis. 

Pathology. — There  are  three  varieties  :  Catarrhal,  ulcer- 
ative, and  interstitial. 

Catarrhal  Appendicitis. — In  mild  cases  the  appearances  are, 
no  doubt,  similar  to  those  observed  in  catarrh  elsewhere,  but 
in  severe  cases  the  wall  of  the  appendix  is  iufiltrated  with 
round-cells,  and  the  mucous  membrane  is  denuded  of  epithe- 
lium and  presents  a  granular  surface.  This  latter  condition 
may  eventuate  in  septic  peritonitis,  chronic  appendicitis  with 
relapses  {recurrent  appendicitis),  or  union  of  the  granulating 
surfaces  with  complete  obliteration   {apjjendicitis  obliterans). 

Ulcerative  Appendicitis. — In  this  type  the  wall  of  the  ap- 
pendix is  the  seat  of  a  more  or  less  localized  ulcer.  It  may 
be  associated  with  the  presence  of  fecal  concretion  or  a  foreign 
body,  or  it  may  be  the  I'esult  of  typhoid  or  tubercular  in- 
fection. 


64  DISEASES    OF   THE    DIGESTIVE   SYSTEM. 

Interstitial  Appendicitis. — In  this  form  the  wall  of  the  ap- 
pendix is  the  seat  of  a  necrosis,  which  is  not  infrequently  gan- 
grenous. It  may  be  primary,  infection  taking  place  through 
the  lymphatics,  or  secondary  to  the  catarrhal  or  ulcerative 
form.  It  terminates  in  perforation,  thereby  exciting  a  most 
virulent  type  of  peritonitis. 

Appendicitis  is  always  due  to  the  action  of  pathogenic 
bacteria,  the  chief  offenders  being  the  bacillus  coli  commu- 
nis, streptococcus  pyogenes,  staphylococcus  pyogenes  aureus, 
typhoid  bacillus,  and  tubercle  bacillus.  Of  these,  the  bacillus 
coli  communis,  a  natural  habitant  of  the  bowel,  is  most  com- 
monly present.  Under  ordinary  conditions  it  is  harmless, 
but  when  the  circulation  of  the  appendix  is  interfered  with 
from  any  cause  or  the  coats  of  the  tube  are  abraded,  infec- 
tion is  liable  to  arise. 

Etiology. — It  is  more  common  in  males  than  in  females. 
It  is  most  frequent  between  the  fifteenth  and  thirtieth  years. 
Exposure,  errors  in  diet,  intestinal  catarrh,  traumatism,  and 
the  lodgement  in  the  appendix  of  fecal  concretions  or  foreign 
bodies  predispose  to  the  disease.  It  may  follow  some  infec- 
tion like  typhoid  fever,  influenza,  or  tuberculosis.  It  may 
be  induced  by  twisting  of  the  appendix. 

Symptoms.— (1)  Sudden  pain,  often  general  at  first,  but 
later  most  marked  in  the  right  iliac  region.  (2)  Circumscribed 
tenderness,  most  frequently  detected  over  McBurney's  point 
— a  point  midway  on  a  line  between  the  umbilicus  and  the 
anterior  superior  iliac  spine.  (3)  Fever,  ranging  between 
100°  and  104°  F.  (4)  Localized  rigidity  in  the  right  iliac 
fossa,  or  the  presence  of  a  definite  tumor.  (5)  Dorsal  decu- 
bitus with  the  right  thigh  flexed.  (6)  Gastro-intestinal  dis- 
turbances— anorexia,  nausea,  vomiting,  constipation,  or  rarely 
diarrhoea. 

Terminations. — Resolution,  general  peritonitis,  and  local- 
ized abscess.  The  location  of  the  abscess  depends  on  the 
position  of  the  appendix.  It  may  be  found  in  either  of  the 
lower  quadrants,  or  beneath  the  diaphragm  (subphrenic 
abscess).  The  pus  may  be  discharged  through  the  abdominal 
walls,  the  bowel,  bladder,  or  vagina,  or  it  may  escape  into 
the  tissues  of  the  lumbar  region  or  thigh.     Appendicitis  oc- 


I 


INTESTINAL   OBSTRUCTION.  65 

casionally  excites  hepatic  abscess,  the  infection  being  carried 
through  the  portal  vein. 

Diagnosis.  Typhoid  Fever.-'— The  gradual  onset,  charac- 
teristic temperature  curve,  epistaxis,  mental  hebetude,  di- 
arrhoea, splenic  enlargement,  and,  later,  the  rash  and  Widal- 
reaction  will  indicate  typhoid  fever. 

Renal  Colic. — This  may  be  recognized  by  the  absence  of 
fever  and  of  local  rigidity,  and  the  presence  of  hsematuria. 

Acute  Inflammation  of  the  Gall-bladder. — Pain  and  tender- 
ness in  the  right  hypochondrium,  a  smooth,  mobile  tumor, 
and  a  history  of  biliary  colic  would  suggest  this  condition. 

Tubal  Disease. — The  history  and  results  of  pelvic  exami- 
nation will  usually  prevent  an  error  in  diagnosis. 

Prognosis. — The  prognosis  depends  on  the  type.  The 
average  mortality  is  about  14  per  cent. 

Treatment. — The  patient  should  be  confined  to  bed  and 
placed  upon  a  restricted  milk  diet.  Warm  or  cold  applica- 
tions may  be  applied  to  the  right  iliac  fossa.  If  there  is 
much  pain,  morphine  may  be  administered  hypodermically. 
Troublesome  constipation  is  best  relieved  by  enemas. 

Surgical  intervention  is  required  under  the  following  cir- 
cumstances :  (1)  At  once  in  cases  beginning  suddenly  with 
great  severity.  (2)  In  ordinary  cases  when  no  improvement 
is  noted  after  the  lapse  of  forty-eight  hours.  (3)  At  any 
time,  should  there  be  a  sudden  increase  in  the  pain  or  a 
rapid  diffusion  of  the  tenderness.  (4)  Whenever  a  well- 
defined  tumor  can  be  detected  in  the  right  iliac  region.  (5)  In 
cases  recognized  as  tuberculous. 

INTESTIT^AL  OBSTKUCTION ;    ILEUS. 

Etiology.  Acute  Obstruction. — (1)  Congenital  occlusion. 
(2)  Intussusception  (Invagination).  (3)  Strangulation,  internal 
or  external.     (4)  Twists  (Volvulus)  or  Knots. 

The  following  are  conditions  which  produce  chronic  obstruc- 
tion, though  at  times  the  symptoms  develop  acutely  :  (1)  Stric- 
ture from  a  heated  ulfcer.  (2)  Unnatural  accumulations,  as 
fecal  masses  (Coprostasis),  foreign  bodies,  gall-stones.  (3) 
Tumors,  within  or  without. 
5 


66  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 


Symptoms.  Acute  Obstruction — (1)  Sudden  pain,  at  first 
paroxysmal,  but  later  continuous.  (2)  Constipation.  (3) 
Vomiting,  persistent,  and  becoming  fecal  (stercoraceous). 
(4)  Abdominal  distention.  (5)  Collapse,  indicated  by  pinched 
features,  cold  extremities,  and  feeble  pulse. 

Diagnosis.  Acute  Generalized  Peritonitis. — The  history, 
early  appearance  of  fever  and  of  diffuse  tenderness,  and  the 
absence  of  persistent  vomiting,  especially  of  a  stercoraceous 
character,  will  indicate  peritonitis. 

Chronic  Obstruction. — These  symptoms  devolop  slowly. 

Congenital  Occlusion. — The  usual  location  is  the  anus  or 
rectum.     It  is  detected  by  direct  examination. 

Intussusception. — The  slipping  of  a  portion  of  intestine  into 
another  portion  immediately  below  it.  It  is  noted  chiefly  in 
children,  and  is  more  common  in  males.  Its  exciting  cause  is 
probably  perverted  peristalsis,  whereby  one  part  of  the  bowel 
is  contracted  while  the  adjacent  part  is  dilated.  In  rare  in- 
stances it  has  been  induced  by  the  traction  of  intestinal  polypi. 
The  usual  seat  is  the  ileo-csecal  region. 

Multiple  invaginations  are  frequently  found  post-mortem, 
which  have  resulted  from  the  irregular  peristalsis  occurring 
just  before  death  ;  they  possess  no  inflammatory  characteris- 
tics. In  invaginations  not  cadaveric,  the  parts  are  injected, 
swollen,  and  covered  with  lymph. 

Diagnosis. — The  symptoms  of  obstruction,  with  the  age ; 
a  "  sausage-shaped"  tumor  in  the  line  of  the  colon  ;  the  rare 
detection  of  the  invaginated  portion  in  the  rectum;  tenesmus; 
and  bloody  mucous  stools  are  the  diagnostic  features. 

Peognosis  . —  Death  usually  results  from  gangrene,  peri- 
tonitis, or  collapse.  A  favorable  termination  sometimes  results 
from  the  escape  of  the  incarcerated  part,  or  by  a  sloughing  ofl" 
of  the  strangulated  portion  and  adhesion  of  the  serous  surfaces. 

Strangulation. — This  often  occurs  in  external  hernia,  when 
it  can  be  recognized  by  an  examination  of  the  inguioal, 
femoral,  and  umbilical  rings. 

Internal  Strangulation  is  due  to  the  slipping  of  a  coil  of 
intestine  through  the  diaphragm,  for^ien  of  Winslow,  an 
abnormal  opening  in  the  omentum  or  mesentery,  or  a  loop  of 
inflammatory  lymph. 


1 


INTESTINAL   OBSTRUCTION.  67 

Diagnosis. — It  might  be  suspected  by  the  absence  of  other 
cause,  by  the  sudden  onset,  or  by  a  history  of  previous 
peritonitis. 

Twist. — Occurs  most  commonly  in  middle-aged  men.  The 
usual  seat  is  the  sigmoid  flexure.  A  relaxed  and  lengthened 
mesentery  is  a  predisposing  factor. 

Diagnosis. — Rarely  possible. 

Stricture. — Usually  results  from  syphilitic,  tuberculous,  or 
dysenteric  ulcers.     The  rectum  is  the  most  common  seat. 

Diagnosis. — Based  on  the  history,  gradual  onset,  results 
of  rectal  examination,  grooved  or  ribbon-like  stools,  bloody 
discharges,  and  visible  peristalsis. 

Unnatural  Accumulations. — Fecal  impaction  is  recognized 
by  the  gradual  onset,  mild  obstructive  symptoms,  history  of 
constipation,  and  a  painless,  irregular,  doughy  tumor  in  the 
line  of  the  colon. 

Gall-stones  may  obstruct  the  ileum  ;  the  history  will  aid  in 
their  recognition. 

Tumors. — The  most  common  tumor  within  the  bowel  is  a 
cancer ;  it  is  usually  located  in  the  sigmoid  flexure  or  rectum. 

Diagnosis. — Age,  gradual  onset,  pain,  bloody  discharges, 
cachexia,  and  a  tumor  in  the  rectum  are  the  characteristic 
features. 

Tumors  of  adjacent  viscera  may  compress  the  bowel.  Their 
recognition  will  depend  upon  physical  examination. 

Treatment  of  Acute  Obstruction, — Food  by  the 
mouth  should  be  withheld.  Ice  may  be  given  to  quench 
thirst.  Nutritive  enemata  should  be  employed  in  the  weak. 
Cathartics  are  contraindicated.  Pain  is  best  relieved  by  the 
administration  of  morphine  hypodermically.  Washing  out 
the  stomach  three  or  four  times  daily  is  recommended  for  the 
persistent  vomiting.  Distention  of  the  large  bowel  with  gas 
or  fluid  should  be  practised  in  doubtful  cases  and  in  intussus- 
ception. It  may  be  accomplished  Ijy  placing  the  etherized 
patient  in  the  knee-elbow  position  and  administering  warm 
water  by  means  of  a  fountain  syringe,  elevated  according  to 
the  patient's  age  from  six  to  fifteen  feet,  the  nozzle  being 
carried  well  up  into  the  bowel.     Senn  recommends  inflation 


68  DISEASES    OF    THE    DIGESTIVE   SYSTEM. 

Avith  atmospheric  air  or  hydrogen  gas.  After  failure  with 
these  methods  celiotomy  should  not  be  delayed  ;  the  earlier 
its  performance  the  greater  the  chance  of  success. 

In  JeGal  impaction  injections  of  warm  water,  oil,  or  an 
aqueous  solution  of  ox-gall  are  efficient.  Salines  may  be 
administered  by  the  mouth.  Electricity  is  sometimes  useful. 
Rectal  accumulations  may  be  removed  by  the  fingers  or  a 
suitable  scoop. 

Strictures  require  surgical  interference. 


a:n^imal.  parasitic  affections. 

Tape-worms. 

Vaeteties.  —  Taenia  solium.  Taenia  saginata.  Bothrio- 
cephalus  latus.     Taenia  echinococcus. 

HiSTOEY. — The  eggs  of  the  tape-worm  are  ingested  by  an 
animal,  and  embryos,  or  proscolices,  are  liberated  in  the 
stomach ;  these  migrate  to  other  organs,  where  they  are 
transformed  into  larvae  or  scolices.  The  encysted  larva,  or 
scolex,  is  termed  a  cysticercus ;  the  condition  is  known  as 
"  measles."  The  mature  worm  develops  in  man  from  the 
cysticercus  contained  in  infected  meat. 

TsBllia  Solium  {Pork  Tape-ivorm). — Is  derived  from  the  hog, 
and  is  two  or  three  yards  in  length.  The  head  is  the  size  of 
that  of  a  pin,  is  provided  with  four  pigmented  •  cup-like 
suckers,  surrounded  by  a  double  row  of  booklets,  and  is 
attached  to  the  body  by  a  thread-like  neck.  The  sexual  ori- 
fice is  in  the  centre  of  the  broad  surface  of  the  segment. 

TaBllia  Saginata  (Tcenia  Mediocanellata). — Is  derived  from 
beef,  and  is  five  or  six  yards  in  length.  The  head  is  larger 
than  that  of  the  taenia  solium,  and  has  four  large  suckers,  but 
no  booklets.  The  segments  are  fatter,  and  the  .  uterine 
branches  are  finer  and  more  numerous  than  in  the  taenia 
solium. 

Bothriocephalus  Latus. — Is  found  especially  in  Europe, 
and  is  derived  from  fish.  The  head  has  no  booklets,  but  two 
lateral  grooves.  The  body  is  very  long.  The  sexual  orifice 
is  on  the  narrow  side  of  the  segment. 


4 


ANIMAL    PARASITIC   AFFECTIONS.  69 

Symptoms. — Often  absent.  Freqnently  there  are  dyspeptic 
symptoms,  colicky  pains,  loss  of  flesh,  capricious  appetite,  and 
sometimes  reflex  nervous  phenomena,  such  as  vertigo,  palpi- 
tation, "  night-terrors,"  convulsions,  itching  in  the  nose,  and 
choreic  movements. 

Tlie  Diagnosis  rests  on  the  discovery  of  the  eggs  or  seg- 
ments in  the  stools. 

Treatment. — A  light  diet  for  a  day  or  two,  and  a  saline 
purge  prior  to  the  administration  of  the  anthelmintic.  After 
an  unsubstantial  breakfast  administer  one  of  the  following 
efficient  remedies  :  Pumpkin  seeds  (two  to  three  ounces) ;  oleo- 
resiu  of  male  fern  (3j-y)»  pelletieriue,  the  alkaloid  of  pome- 
granate (gr.  v)  ;  Kooso  (5ss). 

^   Oleoresin.  aspidii,  fgj  ; 

Pulv.  acacipe  et  sacchar.,  aa  q.  s. 
Aquse  cinaamomi,  q.  s.  ad  f  ^ij. — M. 
Sig.— One  tablespoonful,  repeated  if  required. 

A  purge  should  be  given  a  few  hours  after  the  vermifuge. 
The  treatment  is  successful  only  when  the  head  is  passed. 

Nematodes. 

Ascaris  Lumbricoides  {Bound  Worms). — Life  history  un- 
known. They  are  of  a  pale-pink  color,  and  in  form  resemble 
earth-worms.  They  inhabit  the  small  intestines,  but  occa- 
sionally migrate  into  other  organs,  viz.,  stomach,  bile-ducts, 
and  larynx.     They  are  most  commonly  found  in  children. 

Symptoms. — Often  absent.  Sometimes  there  are  dyspepsia, 
mucous  stools,  colicky  pains,  voracious  appetite,  anaemia,  and 
reflex  nervous  phenomena,  as  '^  night-terrors,"  grinding  of  the 
teeth,  pruritus  of  nose  and  anus,  choreic  movements,  and  con- 
vulsions. 

Treatment — Santonin  (gr.  ^-gr.  iij)  ;  worm-seed  oil  (gtt.  x 
in  capsule  or  on  sugar) ;  fluid  extract  of  spigelia  (f 5j-f3iij)) 
are  efficient  remedies. 

^   Santonini,  gr.  vj  ; 

Hydi-arg.  chlor.  mit.,  gr.  vj  ; 

Sacchari..  gr.  xxiv  ; 
M.  et  ft.  chart.  No.  xij.     (Starr.) 
Sig. — One  powder  morning  and  evening. 


70  DISEASES    OF    THE    DIGESTIVE   SYSTEM. 

Oxyuris  Vermicularis  {Seat-worm,  Pin-worm). — This  is  a 
small  worm,  most  commonly  seen  in  cLiildren,  and  occupies 
the  colon  and  rectum.  It  produces  intense  itching  of  the 
anus,  which  is  worse  at  night.  It  may  migrate  into  the 
vagina  and  excite  pruritus  or  vaginitis,  and  lead  to  mastur- 
bation. 

Treatment. — An  injection  of  water,  followed  by  the  in- 
jection of  two  or  three  ounces  of  an  infusion  of  quassia  chips 
(5ij-iij  to  the  pint). 

Anchylostomum  Duodenale. — A  small  worm,  not  uncom- 
mon in  the  north  of  Europe  and  Egypt.  It  has  been  detected 
most  frequently  in  miners  and  brickmakers,  who  are  probably 
infected  by  drinking  water  containing  the  eggs  of  the  parasite. 
The  worm  inhabits  the  small  intestine. 

Symptoms. — Dyspepsia  and  intense  anaemia.  The  latter 
has  been  termed  Egyptian  chlorosis,  and  may  be  recognized  by 
the  detection  of  eggs  in  the  stools. 

Treatment. — Santonin,  male  fern,  and  thymol  have  been 
recommended. 

Tricocephalus  Dispar  (  Whip-worm). — A  small  worm,  thick 
at  one  end  and  thread-like  at  the  other.  It  occupies  the  colon 
and  caecum,  and  produces  but  little  disturbance. 

Filaria  Sanguinis  Hominis.  —  A  small  thread-like  worm, 
most  commonly  seen  in  the  tropics.  The  adult  occupies  the 
lymphatics,  and  the  female  brings  forth  a  great  number  of 
embryos,  which  soon  find  their  way  into  the  blood-current. 
The  embryos  of  the  most  important  species  of  filaria  {Filaria 
Bancrofii)  are  found  in  the  blood  only  at  night.  The  medium 
of  infection  is  probably  the  mosquito,  which  carries  the  embryo 
from  the  blood  to  the  water. 

Sy'MPTOjMS.  —  Often  absent.  Chyluria,  haematuria,  and 
lymph-scrotum  sometimes  result  from  lymphatic  obstruction. 

Trichina  Spiralis. — A  small  worm  derived  from  the  hog. 
Man  is  infected  by  eating  insufficiently-cooked  pork  contain- 
ing the  encapsulated  worm.  The  worm  is  set  free  in  the 
stomach,  where  it  develops  and  brings  forth  living  embryos. 
These  soon  migrate  into  the  muscles,  where  they  in  turn  de- 
velop, coil  themselves  up,  and  become  encapsulated.  Trich- 
inous  capsules,  impregnated   with   lime-salts,  are   visible  to 


PERITONITIS.  71 

the  naked  eye,  and  are  sometimes  detected  accidentally  at 
autopsies. 

Symptoms  of  Trichinosis. — Sometimes  absent.  When 
large  numbers  have  been  ingested,  gastro-intestinal  symptoms 
develop  in  a  few  days.  These  are :  Pain,  nausea,  vomiting, 
and  serous  diarrhoea. 

Muscular  Symptoms. — In  from  one  to  two  weeks  muscular 
symptoms  develop.  The  muscles  become  swollen,  firm,  ex- 
tremely tender  and  painful.  Movement  is  inhibited,  and 
dyspnoea  results  from  the  involvement  of  respiratory  muscles. 
(Edema,  especially  of  the  face,  is  a  prominent  symptom.  Pro- 
fuse sweating  is  sometimes  observed,  and  high  fever  is  com- 
monly present. 

Blood. — Examination  of  the  blood  shows  a  marked  increase 
in  the  eosinophiles. 

Prognosis. — Depends  on  the  number  of  worms  ingested. 
The  majority  of  patients  recover. 

Treatment. — Prevent  by  thoroughly  cooking  all  pork 
pi'oducts.  In  the  first  stage  use  purgatives.  After  migration 
employ  opium,  warm  fomentations,  and  stimulants. 

PERITONITIS. 

Definition. — Inflammation  of  the  peritoneum. 

Varieties. — According  to  cause,  it  may  be  primary  or 
secondary ;  according  to  extent,  local  or  general ;  according  to 
time,  acute  or  chronic ;  and  according  to  the  exudate,  sero- 
fibrinous, fibrinous,  or  purulent. 

Etiology.  —  Acute  peritonitis  may  be:  (1)  Idiopathic, 
arising  from  exposure  to  cold  and  wet  (rare).  (2)  Traumatic. 
(3)  Perforative,  resulting  from  a  perforating  wound,  or  the 
rapture  of  a  gastric,  typhlitic,  typhoid,  or  dysenteric  ulcer,  or 
a  visceral  abscess.  (4)  Secondary  to  inflammatory  disease  of 
adjacent  viscera,  as  septic  endometritis  and  typhoid  fever. 
(5)  Secondary  to  some  general  morbid  process,  as  rheumatism, 
Bright's  disease,  scarlatina,  tuberculosis,  or  variola. 

Pathology. — In  the  first  stage  the  membrane  is  red, 
sticky,  and  lustreless;  later,  a  sero-fibrinous,  fibrinous,  or  puru- 


72  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

lent  exudate  is  formed.  In  some  cases  the  exudate  is  tinged 
with  blood. 

Symptoms.  Acute  Gener^al  Peritonitis. — Chill ;  moderate 
fever  (102°-103°),  with  its  associated  phenomena ;  a  rapid, 
wiry  pulse ;  abdominal  pain  and  tenderness  so  intense  that 
abdominal  respiration  and  body  movements  are  inhibited ;  the 
patient  lies  on  his  back  with  his  thighs  flexed  ;  the  features 
are  pinched;  the  vomiting  is  persistent;  the  bowels  are  usually 
constipated.    Hiccough  is  a  common  and  troublesome  symptom. 

Iiwpection  reveals  great  abdominal  distention. 

Palpation  elicits  tenderness,  and  rarely  a  friction  fremitus. 

Percussion  at  first  yields  universal  tympany ;  but  later, 
dulness  in  the  flanks  from  the  gravitation  of  the  exudate. 

Diagnosis.  Acute  Miteritis. — Pain  and  tenderness  not  so 
marked,  absence  of  wiry  pulse,  and  diarrhoea  instead  of  con- 
stipation. 

Intestinal  Obstruction. — Unless  associated  with  peritonitis, 
there  is  no  fev^er,  no  wiry  pulse,  nor  extreme  tenderness ;  the 
vomiting  becomes  fecal. 

Hysterical  Abdomen. — This  condition  may  resemble  peri- 
tonitis in  all  particulars.  The  sex  and  personal  history  must 
be  considered.  Fever  is  not  usually  present,  the  pulse  is  not 
rapid  and  wiry ;  when  the  attention  is  distracted  the  pain  may 
vanish. 

Prognosis. — Generally  unfavorable.  Death  usually  results 
in  a  few  days  from  exhaustion.  When  the  process  is  neither 
septic  nor  extensive  recovery  frequently  follows. 

Treatment. — Restrict  the  diet.  Administer  opium  in  full 
doses  to  check  peristalsis  and  relieve  pain.  In  severe  cases 
the  drug  may  be  pushed  until  the  respiration  has  been  reduced 
to  twelve  per  minute ;  apply  leeches  to  the  abdomen,  and  fol- 
low with  light  poultices.  In  some  cases  cold  cloths  are  more 
grateful  than  warm  applications.  In  n  on -perforating  cases, 
salines,  as  Epsom  or  Rochelle  salts  (5ij),  may  be  given  until 
bowels  move  freely.  These  salts,  while  not  increasing  peri- 
stalsis, attract  serum  from  the  turgid  bloodvessels,  and  so 
relieve  congestion.  In  perforating  cases — and  these  are  the 
most  frequent — laparotomy  oifers  the  only  hope  of  cure. 


ASCITES.  73 


Chronic  Peritonitis. 

Etiology. — It  is  usually  tuberculous;  it  may  be  cancerous; 
it  may  be  syphilitic  (occurring  in  young  children);  it  rarely 
follows  Bright's  disease  it  rarely  follows  an  acute  attack; 
it  occurs  in  chronic  alcoholism. 

Pathology. — The  intestines  are  matted  together  by  bands 
of  fibrous  lymph.  The  omentum  is  often  contracted  and 
greatly  thickened.  Effusion  is  usually  present,  but  it  varies 
considerably  in  amount;  it  is  highly  albuminous,  and  in  the 
tuberculous  and  cancerous  varieties  it  may  be  bloody. 

Symptoms. — Fever  is  slight,  and  may  be  absent.  Pain  is  not 
severe,  and  is  commonly  paroxysmal.  There  is  usually  diffuse 
tenderness.     Ansemia  and  emaciation  may  be  marked. 

Inspection. — The  abdomen  is  generally  distended;  often 
irregularly,  from  sacculated  effusions,  inflated  intestinal  coils, 
or  the  projecting  matted  omentum. 

Palpation  may  detect  a  friction  fremitus,  and  the  irregulari- 
ties noted  above.     The  resistance  is  often  great. 

Percussion. — Dulness  in  the  flanks  with  superincumbent 
tympany.  When  the  fluid  is  sacculated,  the  dulness  may  be 
irregularly  distributed.     Fluctuation  can  sometimes  be  elicited. 

Peognosis. — Unfavorable. 

Treatment. — Rest.  Light  diet  and  nutrient  tonics  (malt, 
cod-liver  oil).  Iodide  of  potassium  is  given  for  its  absorbent 
effect.  Iodine  may  be  applied  externally.  When  the  effu- 
sion is  great,  paracentesis  will  be  required.  In  the  simple  and 
tuberculous  forms  laparotomy  has  given  encouraging  results. 

ASCITES. 

Definition. — A  collection  of  -serous  fluid  in  the  perito- 
neal cavity. 

Etiology. — (1)  It  may  result  from  one  of  the  common 
causes  of  dropsy,  viz:  Bright's  disease,  chronic  heart  disease," 
chronic  lung  disease,  anaemia,  and  especially  cirrhosis  of  the 
liver.  (2)  Pressure  of  a  tumor  or  displaced  viscus  upon  the 
portal  vein.  (3)  Chronic  peritonitis.  (4)  Pressure  upon  the 
thoracic  duct  (Chylous  ascites). 


74  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

Symptoms. — When  the  effusion  is  large,  a  sensation  of 
weight,  dyspnoea,  scanty  urine,  constipation,  and  oedema  of 
the  feet  usually  result  from  pressure. 

Physical  Sigiis.  Inspection. — The  abdomen  is  distended, 
the  surface  is  smooth  and  shining;  the  base  of  the  thorax  is 
broadened ;  the  navel  is  more  or  less  obliterated ;  the  super- 
ficial veins  are  frequently  enlarged ;  and,  when  the  patient  lies 
in  the  dorsal  position,  the  flanks  bulge. 

Palpation  may  elicit  fluctuation,  and  in  the  flanks  a  sense 
of  resistance. 

Percussion. — Dulness  and  resistance  in  dependent  parts, 
with  superincumbent  tympany.  Dulness  is  movable;  it  is 
detected  in  the  flanks  when  the  patient  occupies  the  dorsal 
position. 

Aspiration. — The  fluid  is  usually  clear,  straw-colored,  and 
albuminous;  the  specific  gravity  is  from  1012-1016. 

Diagnosis.  Tymj^anites,  or  meteorism. — This  yields  uni- 
versal hyper-resonance  on  percussion. 

Ovarian  Cysts. — The  enlargement  begins  in  the  iliac  fossa. 
The  dulness  is  more  or  less  immovable;  as  the  intestines  are 
pushed  aside,  there  is  dulness  anteriorly,  instead  of  tympany, 
as  in  ascites.  Vaginal  examination  furnishes  important  data; 
the  fluid  has  a  higher  specific  gravity  and  often  coagulates 
spontaneously. 

Distention  of  the  Bladder. — The  location  of  the  dulness  and 
resistance,  the  history,  and  the  results  of  catheterization  will 
render  the  diagnosis  apparent. 

Chronic  Peritonitis. — In  this  condition  the  abdomen  is 
often  irregularly  enlarged,  and  the  seat  of  pain  and  tender- 
ness. Palpation  may  detect  resisting  masses.  On  account  of 
adhesions  the  dulness  may  not  be  movable.  The  fluid  ob- 
tained by  aspiration  is  often  turbid,  contains  more  than  3  per 
cent,  of  albumin,  and  its  specific  gravity  is  above  1015. 

Treatment. — When  possible,  endeavor  to  remove  the 
cause.  Encourage  free  catharsis  by  the  use  of  concentrated 
saline  solutions,  compound  jalap  powder  (gr.  xx-xxx),  ela- 
terium  (gr.  \).  Encourage  free  diuresis  by  the  use  of  citrate 
of  caffeine  (gr.  iij-v),  infusion  of  digitalis  (fsss),  or  Niemeyer's 
pill  (page  90). 


DISEASES   OF    THE    PANCKEAS.  75 

^  Potassii  citrat. ,  gss  ; 
Tinct.  scillse,  f  |ss  _; 
Inf.  digitalis,    f.f  iij  ; 
Aqu8e,'q.  s.  ad  f^vj.— M. 
Sig. — A  tablespoonful  thrice  daily. 

If  the  effusion  is  very  large,  if  the  stomach  is  irritable,  or 
if  internal  remedies  fail  to  give  relief,  tapping  will  be  re- 
quired. 

DISEASES  OF  THE  PANCREAS. 

Pancreatic  Hemorrhage. 

Etiology. — Slight  hemorrhages  may  be  due  to  venous 
congestion,  the  hemorrhagic  diathesis,  or  one  of  the  infectious 
diseases.  The  cause  of  copious  hemorrhage  [pancreatiG 
apoplexy)  is  obscure.  It  has  been  excited  by  traumatism. 
It  has  been  observed  most  frequently  in  males  past  forty 
years  of  age,  in  obese  subjects,  and  particularly  in  those 
addicted  to  the  free  use  of  alcohol. 

Symptoms. — Sudden,  severe  pain  in  the  epigastrium  and 
the  phenomena  of  collapse  are  the  chief  symptoms.  Nausea, 
or  vomiting,  and  tympanites  are  frequently  noted. 

Prognosis. — Most  eases  prove  fatal  within  twenty-four 
hours,  death  being  due  to  reflex  paralysis  of  the  heart 
(Zenker).  Pancreatitis,  cyst  of  the  pancreas,  and  sub- 
phrenic abscess  are  possible  terminations. 

Treatment. — This  consists  in  the  use  of  morphine  for 
the  relief  of  pain,  and  in  measures  intended  to  combat 
collapse. 

Acute  Pancreatitis. 

Varieties. — Hemorrhagic,  gangrenous,  and  suppurative. 

Etiology. — Acute  pancreatitis  often  follows  pancreatic 
hemorrhage,  and  therefore  shares  in  the  etiology  of  the  latter. 
In  addition,  recurrent  gastro-intestinal  catarrh  is  a  frequent 
predisposing  cause. 

Pathology. — In  the  hemorrhagic  form  the  organ  is 
irregularly  enlarged  and  the  seat  of  hemorrhagic  extravasa- 


76  DISEASES    OF    THE    DIGESTIVE   SYSTEM. 

tion.  Opaque,  white  spots,  of  a  tallowy  consistence,  are  fre- 
quently found  in  the  interlobular  tissue,  omentum,  and  sur- 
rounding parts,  and  represent  areas  oi  fat  necrosis. 

Gangrenous  and  suppurative  pancreatitis  are  usually  sec- 
ondary to  the  hemorrhagic  variety  ;  in  the  former  there  are 
more  or  less  extensive  areas  of  necrosis,  and  in  the  latter  single 
or  multiple  abscesses.  Thrombosis  of  the  portal  and  splenic 
veins  is  frequently  encountered. 

Symptoms. — The  symptoms  of  hemorrhagic  and  gangren- 
ous pancreatitis  are  essentially  the  same,  and  consist  in  severe, 
deep-seated  pain  in  the  epigastrium,  vomiting,  abdominal  dis- 
tention, collapse,  and  constipation,  followed  by  more  or  less 
fever.  Suppurative  pancreatitis  usually  runs  a  more  pro- 
tracted course,  often  extending  over  several  weeks,  and  is 
characterized  by  epigastric  pain,  vomiting,  tympanites,  chills, 
and  irregular  hectic  fever. 

Diagnosis.  Intestinal  Obstruction. — In  this  condition 
the  onset  is  less  severe,  fecal  vomiting  is  common,  and 
the  pain  and  distention  are  less  frequently  limited  to  the 
epigastrium. 

The  history  will  sometimes  serve  to  differentiate  the  con- 
dition from  biliary  colic,  perforating  gastric  ulcer,  and  the 
effects  of  an  in-itant  poison. 

Prognosis. — Very  unfavorable.  The  duration  varies 
from  a  few  hours  in  the  severe  hemorrhagic  forms  to  several 
weeks  in  the  chronic  suppurative  variety. 

Treatment. — Palliative.  Under  favorable  circumstances 
operative  interference  may  be  considered. 

Chronic  Pancreatitis. 

Etiology. — It  may  follow  acute  pancreatitis.  The  most 
common  cause  is  chronic  inflammation  of  the  pancreatic  duct 
secondary  to  gastro-intestinal  catarrh.  Obstruction  of  the 
duct  by  calculi  or  tumors  may  induce  it.  It  may  result  from 
syphilis. 

Pa'thology. — The  chief  lesions  are  an  overgrowth  of  the 
fibrous  tissue,  and  atrophy  and  degeneration  of  the  cellular 
elements. 


DISEASES    OF    THE    PANCREAS.  77 

Symptoms. — Dyspepsia,  diarrhoea,  and  paroxysms  of  severe 
epigastric  pain  associated  with  great  anxiety  and  faintness 
are  the  most  characteristic  features.  Jaundice  is  an  occa- 
sional symptom,  and  even  when  it  is  absent  the  stools  may 
be  light-colored  and  contain  free  fat ;  when  the  destruction 
of  the  gland  is  extreme  glycosuria,  with  or  without  the  other 
phenomena  of  diabetes,  is  a  frequent  sym23tom. 

Peognosis. — Serious,  and  when  associated  with  persistent 
glycosuria  it  is  almost  invariably  fatal. 

Teeatment. — The  use  of  fats  and  starches  should  be 
restricted.  Carbonated  waters  are  said  to  increase  pancreatic 
secretion  (Becher).  Pancreatin  or  minced  pancreas  is 
recommended. 

Cancer  of  the  Paiieieas. 

Etiology. — The  disease  most  frequently  occurs  in  males 
past  forty  years  of  age. 

Pathology. — Pancreatic  cancer  is  usually  primary  ;  it 
generally  involves  the  head  of  the  gland,  and  is  commonly 
of  the  scirrhous  variety. 

Symptoms. — These  include  disturbances  of  digestion,  loss 
of  flesh  and  strength,  anemia,  deep-seated  epigastric  pain, 
and  the  presence  of  a  tumor.  The  latter  is  usually  found 
(50  per  cent,  of  cases)  a  little  above  the  navel ;  it  is  but 
slightly  movable,  deep  seated,  and  often  pulsatile  from  its 
relation  to  the  aorta.  The  pain  often  occurs  in  paroxysms, 
especially  at  night,  and  may  be  associated  with  the  symptoms 
of  collapse.  Jaundice  is  a  frequent  symptom,  and  results 
from  the  pressure  of  the  tumor  upon  the  common  bile-duct. 
Pressure  on  the  portal  vein  may  cause  ascites.  Glycosuria 
is  an  occasional  symptom.  The  stools  rarely  contain  free 
fat,  but  the  presence  of  abundant  undigested  muscular  fibers 
in  the  dejections  in  the  absence  of  diarrhoea  is,  according  to 
Fitz,  highly  suggestive. 

Diagnosis. — Gastric  cancer.  In  this  condition  the  tumor 
is  more  freely  movable,  is  usually  associated  with  dilatation 
of  the  stomach  and  with  marked  gastric  symptoms.  Jaun- 
dice is  rare. 


78  DISEASES   OF   THE    DIGESTIVE    SYSTEM, 


Cysts  of  the  Pancreas. 

Etiology. — The  most  common  cause  is  obstruction  of  the 
duct  of  Wirsung  from  stricture,  tumor,  or  impacted  calculus. 
They  are  occasionally  congenital.  Traumatism  is  also  a 
reputed  cause. 

Pathology. — Pancreatic  cysts  may  be  single  or  multi- 
ple. They  lie  behind  the  stomach,  and  may  contain  from  a 
few  ounces  to  several  gallons  of  a  grayish  or  brownish,  viscid 
fluid,  of  an  alkaline  reaction,  of  a  specific  gravity  between 
1010  and  1024,  and  presenting  the  characteristics  of  pancre- 
atic secretion. 

Symptoms. — These  are  very  variable,  the  most  common 
being  epigastric  pain,  vomiting,  constipation,  or  diarrhoea, 
disturbances  of  digestion,  loss  of  flesh,  and  occasionally  in- 
testinal hemorrhage.  Free  fat  and  much  undigested  mus- 
cular fiber  may  be  found  in  the  stools  and  sugar  in  the 
urine.  Physical  examination  often  reveals  in  the  upper 
part  of  the  abdomen  a  smooth,  elastic,  fluctuating  tumor 
which  on  aspiration  yields  a  fluid  capable  of  emulsifying 
fats,  of  converting  starch  into  sugar,  and  of  digesting 
albumin. 

Prognosis  and  Treatment. — The  prognosis  is  guardedly 
favorable.     Large  cysts  should  receive  surgical  attention. 


Pancreatic   Calcnli. 

Pancreatic  calculi  are  probably  due  to  the  retention  of 
secretion  from  catarrh  of  the  duct,  or  pressure  upon  the 
duct  from  a  tumor  or  cyst.  Their  passage  through  the  duct 
excites  'pancreatic  colic,  the  symptoms  of  which  resemble 
biliary  colic,  but  the  pain  is  more  apt  to  radiate  to  the  left 
and  is  unattended  with  jaundice.  The  coexistence  of  glyco- 
suria, and  the  discovery  in  the  stools  of  concretions  con- 
taining chiefly  carbonate  or  phosphate  of  lime,  would  con- 
firm the  diagnosis. 


I 


DISEASES    OF    THE    LIVER.  79 


DISEASES  OF  THE  LIVER. 

The  liver  is  situated  in  the  right  hypochondrium,  with  a 
small  part  projecting  through  the  epigastrium  to  the  left  hypo- 
chondrium. 

Area  of  Liver  Dubiess. — The  absolute  dulness  (part  un- 
covered by  lung)  extends  in  the  mammary  line  from  the  upper 
border  of  the  sixth  rib  to  the  costal  margin ;  in  the  axillary 
line,  from  the  eighth  rib  to  the  eleventh  rib ;  in  the  scapular 
line,  from  the  tenth  rib  to  the  eleventh  rib ;  in  the  median 
line,  the  upper  border  is  lost  in  the  cardiac  dulness,  while  the 
lower  border  lies  midway  between  the  ensiform  cartilage  and 
the  umbilicus.  Slight  dulness  in  the  mammary  line  begins  at 
the  fifth  rib. 

Palpation. 

Palpation  of  the  liver  is  practised  to  determine  position, 
size,  form,  and  consistence ;  and  to  detect  any  tenderness  or 
pulsation. 

Conditions  in  which  the  liver  is  palpable: — 

1.  In  thin  subjects,  the  edge  is  sometimes  palpable  under 
normal  conditions. 

2.  In  very  young  children,  in  whom  the  liver  is  always 
proportionately  large. 

3.  In  depression  of  the  liver,  as  by  a  pleural  effusion  or  by 
a  consolidated  lung. 

4.  When  the  suspensory  ligament  is  relaxed  and  the  liver 
"  wanders." 

5.  In  enlargement  from  any  cause. 

6.  In  certain  abnormalities  of  form,  as  in  the  "  tight-lace 
liver." 

^uperjieial  Irregularities.  —  Small  irregularities  may  be 
noted  in  cancer,  syphilis  of  the  liver,  and  atrophic  cirrhosis. 

Large  prominences  are  sometimes  noted  in  tumors,  abscesses, 
and  hydatid  cysts. 

Consistence. — The  liver  is  firm  to  the  touch  in  hypertrophic 
cirrhosis,  cancer,  congestion,  and  amyloid  disease.     In  abscess 


80  DISEASES    OF    THE    DIGESTIVE   SYSTEM. 

and  hydatid  disease  the  resistance  is  less  marked,  and  some- 
times fluctuation  can  be  noted. 

Tenderness. — The  liver  is  tender  in  acute  congestion,  abscess, 
cancer,  and  in  affections  complicated  with  perihepatitis. 

Pulsation  may  be  detected  in  the  venous  congestion  resulting 
from  tricuspid  regurgitation,  abdominal  aneurism,  in  tumors 
of  the  left  lobe  resting  on  the  aorta,  and  rarely  in  aortic 
regurgitation. 

Percussion. 

Percussion  determines  size  and  resistance. 

The  liver  is  uniformly  enlarged  in  :  (1)  Congestion,  active 
and  passive.  (2)  Fatty  infiltration.  (3)  Amyloid  infiltra- 
tion. (4)  Hypertrophic  cirrhosis.  (5)  Leuksemic  infiltra- 
tion. 

Irregular  enlargements  of  the  liver  are  noted  in  :  (1)  Cancer. 
(2)  Abscess.     (3)  Hydatid  disease.     (4)  Syphilis. 

The  liver  is  diminished  in  size  in :  (1)  Atrophic  cirrhosis, 
late  stage.  (2)  Fatty  degeneration.  (3)  Acute  yellow  atrophy. 
(4)  Senile  atrophy.  The  area  of  hepatic  dulness  may  be 
diminished  from  certain  extrinsic  causes,  namely,  pulmonary 
emphysema  and  excessive  tympanites. 

JAUKDICE  OR  ICTEKUS. 

Definition. — Pigmentation  of  tlie  tissues  and  secretions 
with  bile-pigments. 

Varieties.  —  (1)  Hepatogenous,  or  obstructive  jaundice. 
(2)  Hsematogenous,  or  non-obstructive  jaundice. 

Etiology  of  Hepatogenous  Jaundice.  —  Obstruction 
to  the  outflow  of  bile  leads  to  its  accumulation  and  re-absorp- 
tion. 

Obstruction  may  be  due  to  the  following  causes  : — 

1.  Stricture  of  the  bile-duct,  congenital  or  acquired. 

2.  Catarrh  of  the  bile-ducts,  or  of  the  duodenal  mucous 
membrane  around  the  orifice  of  the  ductus  choledochus. 

3.  Foreign  bodies  in  the  ducts ;  as  gall-stones,  parasites. 

4.  Tumors  of  the  liver  or  of  adjacent  viscera  compressing  the 


ICTERUS    NEONATORUM.  81 

ducts.  Fecal  accumulations,  a  pregnant  uterus,  and  displaced 
organs  may  similarly  compress  the  ducts. 

5.  Lowered  blood  pressure  in  the  vessels  of  the  liver  causing 
increased  tension  in  the  bile-ducts,  as  in  the  simple  icterus  of 
the  new-born  or  that  following  depressing  emotions. 

Symptoms.— The  skin,  mucous  membranes,  and  secretions 
are  stained  yellow.  The  discoloration  is  usually  first  noticed 
in  the  conjunctivse.  The  stools  are  light,  the  urine  is  dark, 
and  in  bad  cases  resembles  porter.  The  pulse  is  usually  slow, 
and  the  temperature  slightly  subnormal.  There  is  always  some 
mental  depression,  and  in  extreme  cases  delirium,  convulsions, 
and  coma  may  develop.  Itching  of  the  skin  is  often  noted, 
and  urticaria  is  a  common  complication.  In  grave  cases  sub- 
cutaneous ecchymoses  may  appear. 

Diagnosis.— Other  discolorations,  like  the  bronze  hue  of 
Addison's  disease,  and  the  green  tint  of  chlorosis,  must  be  dis- 
tinguished from  jaundice ;  but  in  those  cases  the  conjunctiva 
is- white  and  the  urine  lacks  bile. 

Etiology  of  Hjematogenous  or  Non-obstructive 
Jaundice. — This  form  results  from  a  disintegration  of  the 
blood,  or  a  destruction  of  the  liver  substance.  It  is  sometimes 
noted  in  pernicious  ansemia,  and  other  grave  anaemias,  but  it 
more  Commonly  results  from  the  action  of  some  toxic  agent  on 
the  blood;  thus,  it  may  be  observed  in  poisoning  by  phos- 
phorus, arsenic,  and  other  minerals;  in  snake-poisoning,  in 
pyaemia,  and  in  certain  infectious  fevers — as  yellow  fever,  re- 
lapsing fever,  malarial  fever,  and  acute  yellow  atrophy. 

Symptoms. — Much  the  same  as  in  obstructive  jaundice,  but 
the  staining  of  the  skin  is  usually  not  so  intense,  the  stools 
still  contain  bile,  and  grave  cerebral  symptoms  are  more  apt 
to  develop. 

ICTERUS  NEONATORUM. 

Physiological  icterus  in  the  newborn  is  slight,  and  probably 
results  from  the  lowered  pressure  in  the  portal  vessels  caused 
by  ligation  of  the  umbilical  vein,  and  the  subsequent  absorp- 
tion of  bile  from  the  tense  capillary  ducts. 

Pathological  icterus  in  the  newborn  is  marked,  and  com- 
6 


82  DISEASES    OF    THE    DIGESTIVE    SYSTEM, 

monly  proves  fatal.  It  results  from  congenital  stricture  of 
the  duct,  syphilis  of  the  liver,  or  septic  infection  through  the 
umbilical  vein. 

ACHOMA. 

(Cholaemia,  Cholesteraemia.) 

This  term  is  applied  to  a  group  of  symptoms  noted  in  dis- 
eases associated  with  a  destruction  of  the  hepatic  substance, 
and  probably  dependent  upon  the  retention  of  poisons  which 
should  have  been  eliminated  by  the  liver. 

Etiology. — Acholia  occurs  in  acute  yellow  atrophy,  and 
sometimes  at  the  close  of  cancer,  cirrhosis,  and  fatty  degene- 
ration of  the  liver. 

Symptoms.  —  Delirium,  convulsions,  stupor,  and  coma. 
Jaundice  may  or  may  not  be  present.  Subcutaneous  ecchy- 
moses  and  hemorrhages  from  mucous  membranes  are  frequently 
observed. 

CATARRHAL.  JAUNDICE. 

(Catarrhal  Hepatitis,  Catarrh  of  the  Bile-ducts.) 

Etiology. — (1)  The  most  common  cause  is  the  extension 
of  a  gastro-duodenal  catarrh  into  the  ducts.  (2)  Primary  in- 
flammation of  the  ducts  may  result  from  exposure  to  cold  and 
wet.  (3)  It  may  be  induced  by  irritation  from  gall-stones. 
(4)  It  may  be  infectious,  complicating  malaria,  pneumonia, 
relapsing  fever,  and  similar  diseases. 

Pathology. — The  large  ducts  are  particularly  affected  ; 
the  mucous  membrane  is  swollen  and  covered  with  tenacious 
mucus.  When  the  gall-bladder  is  compressed,  bile  is  ejected 
with  less  ease  than  is  natural  through  the  duodenal  orifice. 
When  the  catarrhal  process  is  long-continued,  ulceration  of 
the  ducts,  or  secondary  cirrhosis  (biliary  cirrhosis)  may  result. 

Symptoms. — (1)  Symptoms  of  gastro-duodenal  catarrh 
usually  precede.  These  are :  Coated  tongue,  anorexia,  fetid 
breath,  epigastric  distress,  vomiting,  and  perhaps  diarrhoea. 
(2)  Obstructive  jaundice,  indicated  by  yellow  skin  and  con- 
junctivae, light  stools^  and  dark  urine.     (3)  In  acute  cases, 


» 


BILIARY    CALCULI.  S3 

slight  fever  and  swelling  of  the  liver,  which  is  tender  to  the 
touch. 

Diagnosis. — Usually  easy  ;  the  exclusion  of  other  caasec 
of  jaundice,  and  the  consideration  of  the  age,  acute  onset,  and 
preservation  of  health  will  usually  make  the  diagnosis  appa- 
rent. 

Prognosis. — Favorable.  It  rarely  becomes  chronic  and 
leads  to  biliary  cirrhosis  and  ulceration  of  the  ducts.  The 
average  duration  is  from  a  few  days  to  several  weeks. 

Treatment. — Rest.  Liquid  diet.  Stupes  of  turpentine 
or  of  dilute  nitrohydrochloric  acid  may  be  applied  locally. 
Mild  laxatives  are  often  indicated ;  calomel  may  be  selected. 

^   Hydrarg.  chlor.  mit.,  gr.  ij  ; 
Sodii  bicarb.,  3j. — M, 
Ft.  in  chart.  No.  xii. 
Sig. — One  every  hour  until  a  laxative  effect  is  produced. 

For  the  gastro-duodenal  catarrh,  mineral  waters^  subnitrate 
of  bismuth  (gr.  xx),  nitrate  of  silver  (gr.  ^  q.  d.),  chloride  of 
ammonium  (gr.  x,  q.  d.),  phosphate  of  sodium  (3j  q.  d.),  are 
valuable  adjuncts.  In  persistent  cases  the  daily  irrigation  of 
the  bowel  with  cold  water  (1-2  quarts)  has  been  highly  recom- 
mended ;  the  injections  stimulate  peristalsis  and  thus  favor  the 
expulsion  of  mucus  and  bile  from  the  ducts. 

BILIARY  CALCULI. 

(Gall-stones,  Cholelithiasis.) 

Definition. — Concretions  formed  in  the  gall-bladder,  and 
composed  for  the  most  part  of  bile-elements. 

Etiology. — Female  sex,  age  (after  forty),  heredity,  seden- 
tary habits,  a  rich  diet,  diseases  of  the  liver  which  obstruct 
the  flow  of  bile,  as  tumors,  and  catarrh  of  the  ducts. 

Pathology. — The  stones  may  be  found  in  the  ducts,  but 
they  are  always  formed  in  the  gall-bladder.  There  may  be 
one  or  several  hundred.  When  multiple,  they  are  found  with 
facets,  from  attrition.  The  size  varies  from  a  grain  of  sand  to 
a  large  walnut.  The  color  varies  from  a  light  yellow  to  a 
dark  green.     The  chief  constituent  is  cholesterin,  but  bile- 


84  DISEASES    OF    THE    DIGESTIVE   SYSTEM. 

acids,  bile-pigments,  lime,  and  magnesia  also  enter  into  tlieir 
composition.  On  section,  they  usually  present  a  concentric 
arrangement.  The  pathogenesis  is  not  known ;  a  chemical 
change  in  the  bile  probably  leads  to  a  precipitation  of  the 
cholesterin. 

Events. — (1)  Stones  often  remain  latent  in  the  bladder.  (2^ 
They  may  pass  out  with  pain  and  spasm  (biliary  colic).  (3) 
Impaction.  A  stone  may  obstruct  the  cystic  duct  and  lead  to 
distention  of  the  bladder  with  mucus.  More  frequently  the 
common  duct  is  obstructed  near  its  duodenal  orifice,  when  the 
following  symptoms  result :  Permanent  jaundice,  tenderness, 
exacerbations  of  pain,  and  peculiar  paroxysms  of  fever,  chills, 
and  sweats,  resembling  malaria  (Charcot's  intermittent).  Such 
paroxysms  are  not  necessarily  dependent  on  suppuration, 
although  abscess  may  follow  obstruction.  (4)  Perforation 
into  the  abdominal  sac,  stomach,  or  intestine.  External  per- 
foration is  very  rare.  (5)  After  exit,  stricture  of  the  duct 
may  result  from  ulceration,  or  intestinal  obstruction,  from 
impaction. 

Symptoms  of  Biliary  Colic— Sudden  and  intense  pain 
over  the  liver,  radiating  to  the  back  and  to  the  right  shoulder. 
It  usually  occurs  an  hour  or  two  after  eating.  A  rigor  with 
fever  may  mark  the  onset.  The  symptoms  of  intense  pain 
are  obvious — anxious  face,  cold  sweat,  feeble  pulse,  and  vomit- 
ing. Jaundice  may  follow  from  obstruction.  If  the  stone 
escapes,  it  may  be  found  in  the  stool. 

Diagnosis.  Renal  Colic. — Pain  radiates  from  the  kidney 
down  the  ureter  to  the  penis  ;  blood  in  the  urine ;  no  jaundice. 

Intestinal  Colic. — Pain  radiates  from  the  umbilicus;  flatu- 
lence; no  jaundice;  no  stone  recovered. 

Gastralgia. — Pain  referred  to  stomach  and  back ;  no  jaun- 
dice ;  no  stone  recovered. 

Prognosis. — The  attack  usually  ends  favorably.  Recur- 
rence is  common.  The  prognosis,  as  regards  ultimate  recovery, 
should  be  guardedly  favorable;  complications  are  comparatively 
rare. 

Treatment.-— J'/ie  Attack. — Hot  fomentations.  Morphine 
(gr.  1  to  I")  with  atropine  (gr.  yl-^)  hypodermically.  In  ag- 
gravated cases  anaesthetics  will  be  required. 


ACUTE    INFLAMMATION    OB^    THE    GALL-BLADDER,  85 

The  Interval. — A  regulated  diet,  largely  vegetable.  System- 
atic exercise  should  be  enjoined.  The  flow  of  bile  should  be 
encouraged  by  the  use  of  mineral  waters,  phosphate  of  sodium, 
or  a  vegetable  cholagogue,  like  podophyllin  or  euonymin. 
Catarrh  of  ducts  should  be  relieved  so  tliat  stones  may  escape. 

In  impaction  the  same  treatment  is  indicated  with  counter- 
irritation,  and  the  use  of  some  intestinal  antiseptic,  such  as 
salol,  naphthol,  or  the  salicylate  of  bismuth,  to  replace  the 
antiseptic  elements  of  the  bile. 

In  aggravated  cases  an  exploratory  incision  should  be  made, 
when  a  stone  may  be  removed  from  the  common  duct  (chole- 
dochotomy),  or  from  the  gall-bladder  (cholecystotomy),  or  the 
gall-bladder  removed  (cholecystectomy). 


ACUTE  INFLAMMATION  OF  THE  GALL- 
BLADDER. 

(Acute  Cholecystitis.) 

Etiology. — It  is  frequently  dependent  upon  the  presence 
of  gall-stones.  It  may  follow  (sometimes  remotely)  one  of 
the  acute  infections,  notably  typhoid  fever.  Distention  of 
the  gall-bladder  from  catarrhal  swelling  of  the  cystic  duct  is 
a  possible  cause.  The  micro-organisms  most  frequently 
found  in  the  pus  are  the  colon  bacillus,  typhoid  bacillus,  and 
diplococcus  of  pneumonia. 

Pathology. — The  gall-bladder  is  more  or  less  distended, 
conical  in  shape  and  surrounded  by  adhesions.  Its  walls  are 
opaque,  granular,  and  changed  in  color.  Its  contents  are 
dark,  puriform  or  hemorrhagic.  Its  mucous  membrane  is 
deeply  injected.  Left  to  itself,  suppurative  cholecystitis  may 
eventuate  in  rupture  or  gangrene. 

SYMPTOMS.-^Severe  paroxysmal  pain  in  the  right  hypo- 
chondriac region ;  irregular  fever  with  its  attending  phe- 
nomena ;  nausea  or  vomiting ;  and  locally,  more  or  less 
circumscribed  tenderness  with  rigidity,  and  in  some  cases  an 
elastic  tumor  attached  to  the  liver  ;  chills  and  jaundice  are 
occasional  symptoms. 

Diagnosis. — It  must  be  distinguished  from  appendicitis ^ 


86  DISEASES    OF    THE    DIGESTIVE   SYSTEM. 

subphrenic  abscess,  pancreatic  cyst,  and  pancreatic  hemorrhage. 
The  discriminating  features  are  the  locality  of  the  pain  and 
tenderness,  and  the  seat  of  the  tumor. 

Prognosis. — Grave  in  suppurative  cases.  Of  82  cases, 
53  proved  fatal  (Da  Costa).  Early  operation,  however,  offers 
considerable  hope  of  success. 

Treatment. — This  consists  in  incision  and  free  drainage. 


HYPEREMIA  OF  THE  LIVER 

Varieties. — (1)  Active  hypersemia.  (2)  Passive  hyper- 
emia. 

Etiology. — Active  hypercemia  is  commonly  due  to  dietetic 
indiscretions  (biliousness).  It  may  result  from  over-indulgence 
in  alcohol.  It  is  often  present  in  the  infectious  fevers.  It 
appears  to  arise  idiopathically  in  hot  climates. 

Passive  hypercemia  results  from  diseases  which  obstruct  the 
venous  circulation,  as  chronic  heart  and  lung  disease. 

Pathology. — The  liver  is  enlarged  and  tilled  with  blood. 
In  the  passive  variety,  the  centre  of  the  lobule,  the  area  of  the 
hepatic  vein,  is  deeply  pigmented,  while  the  periphery,  the 
area  of  the  portal  vein,  is  pale.  This  mottled  appearance  has 
given  rise  to  the  term  "  nutmeg  liver."  In  persistent  cases, 
pigmentation,  atrophy  of  liver-cells,  and  overgrowth  of  con- 
nective tissue  result — a  condition  termed  "cyanotic  indura- 
tion." 

Symptoms.  Active  hypercemia. — It  is  associated  with  gastric 
catarrh,  and  the  usual  symptoms  are  :  Coated  tongue,  fetid 
breath,  anorexia,  pain  and  tenderness  in  the  epigastric  and 
hypochondriac  regions,  nausea,  vomiting,  sick-headache,  and 
sometimes  slight  jaundice.     The  liver  may  be  enlarged 

In  the  p)assive  variety,  the  symptoms  are  the  same,  though 
less  marked.  The  liver  is  often  quite  large,  and  in  ex- 
treme cases,  such  as  follow  tricuspid  regurgitation,  it  may 
pulsate. 

Prognosis. — In  simple  active  congestion  the  prognosis  is 
good.  In  passive  congestion  the  prognosis  depends  on  the 
cause. 


CIRRHOSIS    OF    THE    LIVER.  87 

Treatment.  Active  hypercemia  from  dietetic  errors — Re- 
strict the  diet,  apply  counter-irritants,  and  administer  calomel 
and  soda,  thus  : — 

^  Hydrarg.  chlor.  mit.,  gr.  j  ; 
Sodii  bicarb.,  3j. — M. 
Ft.  iu  chart.  No.  vi. 
Sig. — One  every  hour  until  three  or  four  have  been  taken. 

Follow  the  calomel  with  a  laxative  dose  of  sodium  phos- 
phate, Carlsbad  or  Rochelle  salts. 

In  recurring  attacks  of  biliousness,  in  addition  to  dietetic 
and  hygienic  directions,  the  following  will  prove  useful : — 

^.  Mass.  hydrarg.,  gr.  v  ; 
Pulv.  rhei, 

Ext.  gentian.,  aa  gss  ; 

01.  caryophyll.  gtt.  iv. — M.     (Hartshorne.) 
Div.  in  pil.  No.  xx, 

Sig. — One  or  two  occasionally,  as  directed  ;  to  be  continued  if  re- 
quired, thrice  daily  for  several  days. 

In  passive  congestion,  direct  the  treatment  to  the  original 
disease.  In  mild  cases  the  mineral  waters  do  well  (Carlsbad, 
Congress,  and  Friederichshall).  A  mercurial  laxative  may  be 
used  from  time  to  time.  In  obstinate  cases  the  concentrated 
salines  may  be  employed  as  purgatives,  and  wet  cups  applied 
to  the  liver. 

CIRRHOSIS  OF  THE  LIVER. 

(Hob-nailed  Liver,  Interstitial  Hepatitis,  Gin-drinker's  Liver.) 

Definition. — A  chronic  disease  characterized  anatomically 
by  a  hyperplasia  of  the  connective  tissue  and  more  or  less 
destruction  of  the  secreting  cells. 

Etiology. — Male  sex  and  middle  life  are  generally  predis- 
posing factors.  (1)  The  abuse  of  spirituous  liquors  is  a  com- 
mon cause.  (2)  It  follows  chronic  diseases  which  alter  the 
crasis  of  the  blood,  viz  :  Syphilis,  gout,  malaria,  and  tubercu- 
losis. (3)  It  results  from  the  passive  congestion  induced  by 
chronic  heart  and  lung  disease.  (4)  It  may  be  secondary  to 
inflammation   of  the    bile-ducts.     It   is   sometimes   seen    in 


88  DISEASES    OF    THE    DIGESTIVE   SYSTEM. 

children ;  and  in  them,  congenital  syphilis  and  the  infectious 
fevers  appear  to  be  the  exciting  causes. 

Pathology. — Two  varieties  have  been  recognized:  (1) 
Atrophic  cirrhosis,  and  (2)  hypertrophic  cirrhosis. 

Atrophie  Cirrhosis. — In  the  early  stages  the  liver  is  some- 
what large  from  hypersemia.  In  the  advanced  stage  the 
liver  is  small,  firm,  gray  in  color,  and  covered  with  numerous 
granulations  ("  hob-nails").  A  section  of  the  liver  presents 
a  network  of  fine  and  of  coarse  pearly  bands  of  connective 
tissue.  The  contraction  of  this  connective  tissue  is  responsi- 
ble for  the  reduction  in  size  and  granular  surface. 

Microscopic  examination  reveals  an  overgrowth  of  con- 
nective tissue,  of  a  fibrous  character,  and  chiefly  perilobular 
in  distribution.  The  contraction  of  this  tissue  constricts  the 
branches  of  the  portal  vein  and  causes  atrophy  and  degenera- 
tion of  the  liver  cells. 

The  term  hypertro])hic  cirrhosis  is  applied  to  a  condition 
in  which  the  connective-tissue  hyperplasia  starts  from  the 
periphery  of  the  caj)illary  bile-ducts,  instead  of  from  the 
ramifications  of  the  portal  vein,  as  in  atrophic  cirrhosis.  The 
symptoms  of  portal  obstruction  are  not  marked,  but  jaundice 
is  a  prominent  feature. 

The  liver  is  large,  yellow  in  color,  and  its  surface  is  smooth 
or  finely  granular.  The  increased  size  is  due  to  a  great  over- 
growth of  connective  tissue,  and  to  preservation  of  the  hepatic 
parenchyma. 

The  connective  tissue  is  not  fibrous,  but  embryonal  (round- 
cell  infiltration),  and  therefore  does  not  contract.  Its  pres- 
ence, however,  between  the  liver  cells  leads  to  compression 
of  the  biliary  capillaries. 

Symptoms  of  Ateophic  Cieehosis. — Obstruction  to  the 
portal  circulation  induces  congestion  of  the  stomach  and  intes- 
tines, and  hence  the  initial  symptoms  are  those  of  gastro- 
intestinal catarrh.  These  are :  Coated  tongue,  anorexia, 
fulness  and  distress  after  eating,  vomiting  frothy  mucus, 
flatulence,  constipation,  and  dark  urine.  These  phenomena 
may  last  for  months  or  years. 

As  the  obstruction  becomes  greater  the,  portal  blood  finds 
new  channels,  and  the  superficial  abdominal  veins  enlarge, 


CIRRHOSIS   OF   THE    LIVER.  89 

notably  around  the  umbilicus,  forming  tbe  so-called  "  caput 
medusae."     Hemorrhoids  result  from  the  same  cause. 

Engorgement  of  the  portal  system  leads  to  ascites  and  swell- 
ing of  the  feet,  to  hemorrhage  from  the  stomach,  bowel,  or  some 
distant  organ,  and  to  enlargement  of  the  spleen. 

The  liver  is  at  first  large,  but  is  subsequently  contracted. 

There  is  loss  of  flesh  and  strength.  The  skin  is  muddy  in 
appearance.  Jaundice  is  not  common,  and  when  present 
results  from  catarrh  of  the  bile-ducts.  Death  results  from 
exhaustion,  hemorrhage,  intercurrent  disease,  or  from  a  group 
of  cerebral  symptoms  (delirium,  convulsions,  and  coma)  which 
are  probably  due  to  the  retention  of  some  toxic  agent  which 
the  liver  should  eliminate. 

Hypertroph'iG  Ch^rhosis. — Jaundice  is  marked.  The  liver  is 
enlarged,  smooth,  and  firm.  Symptoms  of  portal  obstruction, 
such  as  dropsy  and  hemorrhages,  are  not  common.  The 
spleen  is  swollen.  Moderate  fever  and  leucocytosis  are 
generally  present,  and  favor  the  view  that  the  disease  is  of  an 
infectious  natnre.  The  disease  may  last  one  or  two  years, 
but  an  abrupt  termination  in  convulsions  and  coma  may  occur 
at  any  time. 

Complications. — Tuberculosis,  interstitial  nephritis,  cardiac 
hypertrophy,  and  hemorrhage. 

Diagnosis. — In  the  early  stage  the  diagnosis  can  only  be 
suspected.  In  the  drunkard,  chronic  gastric  catarrh  with  en- 
largement of  the  liver  would  strongly  indicate  cirrhosis. 

Cancer. — History,  greater  cachexia,  jaundice  more  common, 
and  ascites  less  frequent,  liver  enlarged  and  studded  with 
nodules,  other  organs  affected,  pain,  and  short  duration. 

Chronic  Peritonitis  ivith  effusion. — This  is  usually  tuberculous 
or  cancerous.  The  short  duration,  the  abdominal  tenderness, 
the  lack  of  a  uniform  enlargement  from  bands  of  lymph,  the 
absence  of  symptoms  indicating  portal  obstruction,  the  normal 
size  of  the  liver,  after  tapping,  and  the  turbid  sanious  fluid 
will  indicate  chronic  peritonitis. 

Prognosis. — Unfavorable.  It  may  be  arrested  in  the  early 
stage.  The  entire  duration  may  be  many  years,  but  death 
usually  results  in  from  one  to  three  years  after  symptoms  of 
portal  obstruction  have  appeared. 


90  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

Treatment. — Light  nutritous  diet.  Rest.  Alcohol  must 
be  interdicted.  Treat  the  gastric  catarrh  with  nitrate  of  silver, 
bismuth,  mineral  waters,  and  antiseptics  (creosote  or  salicylate 
of  bismuth).  Iodide  of  potassium  in  small  doses,  well  diluted, 
may  be  of  service  in  the  early  stage.  Counter-irritation  over 
the  liver  should  be  frequently  practised. 

Ascites. — Concentrated  saline  purges  in  the  morning  (Epsom 
salts  ^ss  in  enough  water  to  dissolve  it).  Diuretics,  as  digitalis 
or  caffeine.     Niemeyer's  pill  may  be  useful : 

^   Mass.  hydrarg.,  gr.  xij  ; 

Pulv.  digitalis,  gr.  xij  ; 

Pulv.  scillse,  gr.  xij. — M. 
Ft.  in  pil.  No.  xii. 
Sig.  —One  pill  thrice  daily. 

When  the  effusion  is  very  large,  internal  remedies  fail,  and 
paracentesis  will  be  required. 

The  Operation. — Empty  the  bladder.  Ansesthetize  a  point 
in  the  linea  alba  midway  between  the  umbilicus  and  pubis. 
Tap  with  a  small  trocar,  and  have  a  long  rubber  tube  at- 
tached to  the  canula  for  conveying  the  liquid  into  a  conve- 
nient receptacle.  When  the  liquid  stops  flowing  withdraw  the 
canala,  cover  the  wound  with  adhesive  plaster,  and  apply  an 
abdominal  binder.  Observe  strict  antisepsis.  The  operation 
is  free  from  danger. 

ABSCESS  OF  THE  LIVER. 

Etiology. — (1)  The  presence  in  the  liver  of  the  amoeba  coli 
of  dysentery.  (2)  Traumatism.  (3)  Foreign  bodies,  gall- 
stones, retained  bile,  and  hydatid  cysts.  (4)  Septic  emboli ; 
they  may  come  through  the  hepatic  artery,  but  usually  they 
come  through  the  portal  vein  from  gastric  ulcers,  or  the  ulcers 
of  dysentery,  typhlitis,  or  typhoid  fever,  and  produce  a  puru- 
lent inflammation  of  the  vein  (suppurative  pylephlebitis). 

Pathology. — The  abscess  following  amoebic  dysentery  is 
often  single,  and  usually  occupies  the  right  lobe. 

Embolic  abscesses  are  always  multiple. 

Events. — Hepatic  abscess  may  kill  by  exhaustion  or  by 
rupture   into   adjacent  viscera.     Recovery  may  follow  after 


CANCER   OF   THE   LIVER.  91 

operation  or  spontaneous  evacuation ;  and  the  latter  may  be 
external, through  the  bronchial  tubes, or  through  the  bowel. 

Symptoms. — Hectic  symptoms  :  Fever,  high  in  the  evening 
and  low  in  the  morning,  sweats,  and  chills.  Local  symp- 
toms :  The  liver  is  enlarged,  painful,  and  tender.  There  may 
be  bulging  and  even  fluctuation.  Pus  may  be  detected  by  the 
aspirating  needle.  Jaundice  from  obstruction  is  sometimes 
present. 

Diagnosis.  Hydatid  Cysts. — Long  duration,  history,  clear 
fluid  on  aspiration,  absence  of  pain,  and  absence  of  hectic 
symptoms. 

Cancer. — History,  cachexia,  the  involvement  of  other  organs, 
multiple  and  firm  nodules,  and  absence  of  hectic  symptoms. 

Intermiitent  Fever  due  to  Impacted  Calculi. — Fever  and  pain 
are  periodic ;  the  health  may  be  well  preserved ;  the  liver  is 
not  enlarged.     The  condition   may  persist  for  several  years. 

Prognosis. — Embolic  abscesses  (multiple)  prove  invariably 
fatal.  Traumatic  abscesses  or  abscesses  due  to  a  amoebic 
dysentery  may  terminate  favorably  after  spontaneous  or  in- 
duced evacuation. 

Treatment. — This  consists  in  evacuation  of  the  pus  and 
the  establishment  of  thorough  drainage. 

CANCER  OF  THE  LIVER. 

Etiology. — Male  sex,  age  (after  forty),  heredity,  trau- 
matism, and  obstruction  from  gall-stones  are  predisposing 
factors. 

Pathology. — It  is  generally  secondary.  The  liver  is  en- 
larged, and  studded  with  numerous  grayish-white  nodes,  some 
of  which  project  from  the  surface.  The  superficial  nodes  are 
often  depressed  at  the  centre. 

Symptoms. — (1)  Severe  pain  and  tenderness.  (2)  Cachexia, 
i.  e.  loss  of  flesh  and  strength,  with  pallor.  (3)  Pressure- 
symptoms :  jaundice  is  common  but  ascites  is  rare.  (4)  Phy- 
sical examination  :  the  liver  is  enlarged,  its  surface  is  nodular, 
and  the  central  depression,  or  umbilications,  can  often  be 
detected.  (5)  Synaptoms  of  the  primary  growth  which  is 
usually  in  the  stomach. 


02  DISEASES   OP   THE   DIGESTIVE   SYSTEM. 

Fever  is  generaly  absent,  but  secondary  perihepatitis  or 
suppuration  of  the  cancerous  nodules  may  induce  it. 

Diagnosis.  HyjjertrojjJiic  Cirrhosis. — Liver  is  smooth  and 
painless,  the  duration  is  longer,  cachexia  is  not  marked,  and 
there  is  no  indication  of  a  primary  cancer. 

Hydatid  Cysts. — Health  preserved,  tumor  elastic  or  fluctuat- 
ing, no  pain,  jaundice  uncommon,  aspiration  yields  a  clear 
fluid  containing  hooklets. 

Abscess. — History,  short  duration,  hectic  fever,  and  results 
of  aspiration. 

Peognosis.  —  Absolutely  fatal.  Duration,  from  a  few 
months  to  a  year. 

Treatment. — Palliative. 

AT^IYLOID  LIVER. 

("Waxy  Liver,   Lardaceous  Liver.) 

Definition. — An  enlargement  of  the  liver  due  to  the  de- 
position of  an  albuminoid  substance. 

Etiology. — (1)  Prolonged  suppuration  ;  (2)  syphilis  ;  (3) 
tuberculosis,  and  (4)  chronic  malaria  are  causal  factors. 

Pathology. — The  liver  is  very  large,  hard,  and  smooth. 
The  edge  is  blunt.  On  section,  the  surface  is  "  waxy,"  and  a 
dilute  solution  of  iodine  strikes  a  mahogany-red  color  with  the 
amyloid  material.  The  degenerative  process  begins  in  the 
walls  of  the  capillaries  and  spreads  to  the  connective  tissue. 

Symptoms. — Failure  of  general  health  with  anaemia.  The 
liver  is  enlarged,  smooth,  firm,  and  painless,  and  presents  a 
blunt  edge.  The  spleen  and  kidneys  share  in  the  degeneration, 
and,  as  a  result,  the  spleen  is  enlarged  and  the  urine  is  albu- 
minous. 

Diagnosis. — The  history,  the  smooth,  painless,  enlarge- 
ment of  the  liver  without  jaundice,  and  the  involvement  of  the 
kidneys  and  spleen,  are  the  diagnostic  phenomena. 

Prognosis. — Unfavorable. 

Treatment. — Remedies  must  be  directed  to  the  causal 
disease.  Nutrients  and  tonics  are  indicated.  Absorbents,  like 
the  iodides,  mercurials,  and  ammonium  chloride,  have  been 
recommended,  but  are  valueless. 


i 


HYDATID   CYSTS   OF   THE   LIVER,  93 

HYDATID  CYSTS  OF  THE  LIVER. 

(Echinococcus  of  the  Liver.) 

Etiology  and  Pathology. — Hydatid  cysts  are  formed 
by  the  embryos  of  the  taenia  echinococcus,  a  small  tape-worm 
inhabiting  the  intestines  of  the  dog. 

The  eggs  of  the  worm  are  accidentally  ingested  by  man,  and 
embryos  are  liberated  in  the  stomach,  whence  they  may  migrate 
to  any  organ  ;  the  liver  however  is  most  commonly  affected 
through  the  portal  vein.  The  fixed  embryo  soon  develops 
into  a  cyst  which  is  composed  of  an  external  laminated  layer 
and  an  internal  breeding  layer.  A  connective-tissue  layer  is 
formed  on  the  outside  from  irritation. 

The  cyst  contains  a  clear  non-albuminous  fluid  which  has  a 
specific  gravity  of  1005  to  1007,  and  which  is  rich  in  chlorides. 

Scolices  or  larvse  develop  from  the  breeding  layer ;  they 
are  provided  with  four  suckers  and  a  circle  of  booklets,  and 
produce  daughter-cysts  within  the  parent-cyst.  When  ingested 
by  the  dog  the  larvse  develop  into  mature  tape-worms. 

Symptoms. — Small  cysts  excite  no  symptoms.  There  is 
often  a  slowly-developing,  irregular  enlargement  of  the  liver ; 
if  the  cyst  is  superficial,  an  elastic  or  fluctuating  mass  may  be 
detected  on  palpation. 

On  percussion  a  peculiar  vibratory  sensation  (hydatid  thrill) 
may  be  imparted  to  the  hand.  Aspiration  yields  a  clear  fluid 
containing  booklets. 

Fever,  pain,  and  jaundice  are  usually  absent. 

Events. — (1)  It  may  reach  a  certain  size,  and  then  remain 
latent.  (2)  Trifling  injury  may  convert  it  into  an  abscess. 
(3)  Rupture  of  the  cyst  externally  or  into  neighboring  organs 
may  result  in  death  or  in  recovery. 

Diagnosis. — Slow  development,  irregular  enlargement, 
elastic  feel,  the  results  of  aspiration,  and  the  absence  of  pain, 
fever,  and  jaundice  are  the  diagnostic  features.  Suppurating 
cysts  will  be  regarded  as  abscesses.  An  upward-growing 
cyst  may  present  the  signs  of  a  pleural  effusion. 

Prognosis. — Guardedly  favorable. 

Treatment. — This  consists  in  incision,  evacuation,  and 
drainage. 


94  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

ACUTE  YELLOW  ATROPHY. 

(Acute  Parencliyraatous  Hepatitis;  Malignant  Jaundice.) 

Definition. — A  rare  and  grave  disease  characterized  ana- 
tomically by  a  rapid  destruction  of  the  liver  tissue,  and  mani- 
fested by  jaundice,  hemorrhages,  a  reduction  in  the  size  of  the 
liver,  and  marked  cerebral  phenomena. 

Etiology. — Female  sex,  pregnancy,  early  life,  are  predis- 
posing factors. 

Alcoholic  excesses,  emotional  excitement,  and  syphilis  have 
been  given  as  exciting  causes. 

The  rapid  course,  widespread  lesions,  and  the  fact  that  it 
has  occurred  endemically  suggest  an  infectious  origin. 

Pathology. — From  destruction  of  its  substance  the  liver 
is  quite  small.  The  capsule,  being  too  large  for  the  shrunken 
organ,  is  wrinkled.     The  surface  is  yellowish-red  and  mottled. 

Histology. — Fat  drops,  molecular  debris,  fat  crystals,  and 
crystals  of  leucin  and  tyrosin  take  the  place  of  normal  liver- 
cells.     The  other  organs  reveal  fatty  degeneration. 

Symptoms. — (1)  The  initial  symptoms,  which  are  those  of 
catarrhal  jaundice,  are  :  Malaise,  slight  fever,  coated  tongue, 
nausea,  vomiting,  and  jaundice.  (2)  Nervous  symptoms  fol- 
low ;  these  are :  Severe  headache,  delirium,  convulsions,  and 
coma.  Sometimes  these  symptoms  precede  the  jaundice.  (3) 
The  urine  is  scanty,  and  contains  albumin,  blood,  tube-casts, 
and  crystals  of  leucin  and  tyrosin.  (4)  Hemorrhages  are  com- 
mon, the  skin  may  be  covered  with  ecchymoses,  and  bleeding 
from  the  mucous  membranes  may  occur.  (5)  The  area  of 
hepatic  dulness  is  diminished,  but  the  area  of  splenic  dulness 
is  increased. 

Diagnosis. — The  grave  cerebral  symptoms,  reduced  hepatic 
dulness,  and  hemorrhages  will  separate  it  from  catarrhal  jaun- 
dice. 

Phosphorus-poisoning. — History,  phosphorus  in  the  urine, 
primary  enlargement  of  the  liver,  and  the  great  severity  of 
the  initial  gastric  symptoms. 

Prognosis — Almost  invariably  fatal.  Death  results  within 
a  week  after  the  appearance  of  cerebral  symptoms. 

Treatment. — Palli  ati  ve. 


DISEASES 

OP 

THE    KIDNEYS 


THE  URIKE. 

Normal  urine  is  a  pale,  amber-colored  fluid,  of  acid  reaction, 
having  a  specific  gravity  of  1015  to  1025,  and  amounting  in 
quantity  to  about  fifty  ounces  in  twenty-four  hours. 

Polyuria. — An  increased  flow  of  urine. 

Temporary  polyuria  results  from  :  (1)  Excessive  ingestion 
of  fluids.  (2)  Diuretics.  (3)  Suppression  of  perspiration.  (4) 
Crises  of  certain  febrile  diseases,  and  certain  neurotic  manifes- 
tations, such  as  excitement,  neuralgia,  and  hysteria.  (5)  Ab- 
dominal enlargements,  as  in  pregnancy,  effusions,  and  tumors. 
(6)  Removal  of  some  temporary  obstruction  in  the  urinary 
passages. 

Permanent  polyuria  results  from  :    (1)  Diabetes  mellitus. 

(2)  Diabetes  insipidus.  (3)  Chronic  interstitial  nephritis.  (4) 
Amyloid  kidney. 

The  urine  is  diminished  or  suppressed  (anuria)  in  the  fol- 
lowing conditions:  (1)  Excessive  secretion  through  other 
channels,  as  in  free  perspiration  and  diarrhoea.     (2)  In  fever. 

(3)  Passive  renal  congestion,  from  obstructive  heart,  lung,  or 
liver  disease.  (4)  Organic  obstruction  in  the  urinary  pass- 
ages. (5)  In  acute  and  chronic  parenchymatous  nephritis. 
(6)  Nervous  causes,  as  in  hysteria,  and  in  the  reflex  inhibition 
after  abdominal  injuries  or  operations. 

Urea. — Urea  results  from  the  perfect  decomposition  of  the 
nitrogenous  elements  of  food  and  tissues.    It  is  perfectly  solu- 

(95) 


96  DISEASES   OF   THE    KIDNEYS. 

ble  in  urine,  but  the  nitrate  of  urea  crystallizes  in  the  form  of 
transparent  imbricated  plates  when  nitric  acid  is  added  to  urine 
that  has  been  partially  evaporated. 

The  amount  of  urea  excreted  varies  greatly  in  health.  Nor- 
mal urine  contains  about  2  to  2J  per  cent,  of  urea. 

It  is  increased:  (1)  After  the  ingestion  of  much  albuminous 
food.  (2)  After  exertion.  (3)  In  acute  inflammatory  pro- 
cesses and  in  fevers.     (4)  In  diabetes. 

It  is  diminished:  (1)  In  nephritis.  (2)  In  organic  diseases 
of  the  liver.  (3)  In  wasting  diseases  and  in  ansemia.  (4)  In 
starvation. 

Fowler's  Hypochlorite  Test  for  Urea. — Add  to  1  volume  of 
the  urine  7  volumes  of  Labarraque's  solution  of  chlorinated 
soda.  Shake  the  jar  containing  the  mixture  occasionally,  and 
stand  it  aside  for  two  hours,  when  the  urea  will  have  been 
decomposed.  Now  take  the  specific  gravity  of  the  quiescent 
fluid. 

2d.  Ascertain  the  specific  gravity  of  the  mixture  of  urine  and 
Labarraque's  solution  before  decomposition.  To  do  this,  mul- 
tiply the  specific  gravity  of  the  pure  Labarraque's  solution  by 
7,  add  this  to  the  specific  gravity  of  the  pure  urine,  and  divide 
by  8.  The  result  is  the  specific  gravity  of  the  mixed  fluid. 
From  this  subtract  the  specific  gravity  of  the  quiescent  mix- 
ture after  decomposition  of  the  urea,  multiply  the  difference 
by  .77,  and  the  result  is  the  percentage  of  urea. — Tyson. 

Lithuria. — Uric  acid  or  urates  in  the  urine.  These  sub- 
stances are  formed  by  the  imperfect  metamorphosis  of  tissues 
and  nitrogenous  food.  When  they  are  in  excess  the  urine  is 
heavy,  dark  in  color,  and  on  cooling  throws  down  a  brick-red 
deposit,  termed  "  lateritious"  {later,  a  brick). 

INIicroscopically,  uric  acid  appears  as  reddish -yellow  rhombic 
prisms  or  lozenge-shaped  crystals. 

Amorphous  urates  appear  as  fine,  dark,  and  opaque  granules. 

Crystalline  urates  appear  as  needles,  dumb-bells,  or  as 
globular  masses  from  which  sharp  spines  project. 

Murexide  Test  for  Uric  Acid  and  its  Salts. — Evaporate  a  little 
urine  in  a  porcelain  dish,  add  a  drop  or  two  of  strong  mine 
acid,  and  heat  again  to  dryness.     Cool,  and  add  a  drop  of 


I 


THE    URINE. 


y? 


liquor  ammoniee,  and  the  beautiful  purple  color  of  murexide 
is  developed. 

Fig.  3. 


Uric  acid  and  uric  acid  salts. 

Urates. — The  urates  are  present  in  small  quantity  in  normal 
urine.     They  may  become  perceptible  or  transiently  increased  : 

(1)  In  urine  exposed  to  a  cold  atmosphere.  (2)  In  urine  made 
scanty  by  free  perspiration  or  diarrhoea.  (3)  When  the  acidity 
of  the  urine  is  temporarily  increased.  (4)  After  the  excessive 
indulgence  in  nitrogenous  food. 

The  urates  are  increased  pathologically  in  many  diseases 
which  directly  or  indirectly  interfere  with  tissue  or  food  metab- 
olism,   notably    in :    (1)    Lithsemia    or   the    gouty    diathesis. 

(2)  Fever.  (3)  Extreme  ansemia,  (4)  Diseases  of  tlie  lungs — 
from  interference  with  oxidation. 

Leucin  and  Tyrosin. —  These  substances  are  found  in  the  urine 
in  certain  specific  fevers,  in  grave  anaemia,  and  especially  in 
fatty  degeneration  of  the  liver  resulting  either  from  j^hos- 
phorus-poisoning  or  acute  yellow  atrophy. 

They  may  be  detected  by  evaporating  a  few  drops  of  the 
urine  on  a  glass  slide.  Leucin  appears  in  the  form  of  small, 
round,  glistening  spheres,  resembling  fat  drops,  but  unlike  the 
latter  they  are  insoluble  in  ether.  Tyrosin  appears  in  the 
form  of  intersecting  tufts  of  fine  acicular  crystals. 
7 


M8 


DISEASES    OF    THE    KIDNEYS. 

Fig.  4. 


a.  Tyrosin  crystals.    &.  Leucin  crystals. 

Phosphates. — There  are  two  forms,  amorphous  and  crystal- 
line. 

Amorphous  earthy  phosphates  are  found  in  alkaline  urine, 
and  are  precipitated  by  adding  a  few  drops  of  liquor  ammonise 
to  the  urine. 

Crystallized  phosphate  of  lime  appears  as  stellar  or  rod- 
shaped  crystals  which  are  soluble  in  acetic  acid. 

Fig.  5. 


Triple  phosphate. 


The  ammonio-magnesian  phosphate,  or  triple  phosphate,  ap- 
pears in  decomposing  urine  as  transparent  coffin-shaped  prisms. 
They  may  resemble  crystals  of  oxalate  of  lime,  but,  unlike 
the  latter,  are  freely  soluble  in  acetic  acid. 


THE    URINE. 


99 


The  presence  of  phosphates  in  the  urine  is  no  indication  of 
excess,  for  when  normal  in  amount  they  are  often  precipitated 
in  urine  that  is  temporarily  alkaline. 

The  detection  of  triple  phosphates  in  newly-voided  urine 
indicates  decomposition  in  the  bladder,  a  condition  residting 
from  vesical  catarrh. 

Phosphates  are  often  increased  in  nervous  dyspepsia,  melan- 
cholia, and  neurasthenia. 

Chlorides. — The  quantity  of  these  salts  is  increased  :  ^(1) 
After  exertion.  (2)  During  the  absorption  of  mechanical  or 
inflammatory  effusions.  (3)  In  intermittent  fever,  from  the 
destruction  of  corpuscles. 

The  quantity  is  decreased  :  (1)  In  most  febrile  diseases. 
(2)  In  nephritis.  (3)  In  many  wasting  diseases.  (4)  Espe- 
cially in  pneumonia. 

Test. — We  may  thus  roughly  estimate  the  quantity.  Add 
a  few  drops  of  strong  nitric  acid  to  the  urine,  remove  any 
albumin  that  may  be  present,  and  then  add  to  the  clear  urine 
a  little  of  a  strong  solution  of  nitrate  of  silver.  The  abund- 
ance of  the  white  precipitate  will  indicate  the  quantity  of  chlo- 
rides present. 

Fig.  6. 


Oxalate  of  lime. 


Oxaluria. — Oxalate  of  lime  appears  in  the  urine  as  dumb- 
bell-shaped crystals^  or  as  minute  highly  refracting  octahedra. 


100  DISEASES    OF   THE   KIDNEYS. 

Many  conditions  prodnce  them.  They  are  found  :  (1)  After 
eating  certain  fruits  and  vegetables,  as  rhubarb,  cauliflower, 
and  pears.  (2)  In  certain  diseases,  notably  nervous  dyspepsia, 
hypochondria,  melancholia,  diabetes,  and  wasting  diseases. 

In  these  cases  the  oxalates  result  from  the  imperfect  metab- 
olism of  organic  substances. 

Urobilinuria. — Urobilin  is  a  coloring  principle  derived  from 
the  blood.  When  present  in  the  urine  in  large  amount  it  pro- 
duces a  reddish-brown  color  ;  when  deposited  in  the  tissues  it 
produces  a  form  of  jaundice  which  has  been  called  urobilin- 
icterus  (Jaksch). 

Urobilinuria  occurs:  (1)  Occasionally  in  health.  (2)  In 
pyrexia.  (3)  After  the  absorption  of  hemorrhagic  effusions. 
(4)  In  liver  disease.     (5)  In  grave  anaemia. 

Glucosuria,  or  Glycosuria, — Glucose  in  the  urine. 

Its  Causes. — (1)  Normal  urine  contains  a  trace.  (2)  Diabetes 
mellitus.  (3)  Certain  diseases,  as  gout,  chorea,  tetanus,  and 
functional  nervous  affections.  (4)  Ingestion  of  much  sacchar- 
ine material.  (5)  Pregnancy.  (6)  Toxic  substances  in  the 
blood,  as  the  nitrites,  phloridzin,  and  carbon  monoxide. 
(7)  Lesions  of  the  pancreas,  liver,  and  base  of  the  brain. 

Qualitative  Tests  for  Glucose. — The  copper  tests  are  commonly 
employed,  and  depend  on  the  power  which  glucose  possesses  of 
converting  blue  oxide  of  copper  into  the  orange-yellow  sub- 
oxide. 

Trommer^s  Test. — Add  to  the  suspected  urine  half  its  volume 
of  liquor  potassse,  and  if  any  precipitate  falls  filter  the  solution  ; 
then  add  one  or  two  drops  of  a  weak  solution  (1-30)  of  sulphate 
of  copper,  and  heat  the  resulting  mixture.  If  sugar  is  present, 
a  dense  yellow  or  red  precipitate  falls. 

Simple  decolorization  of  the  fluid  is  no  proof  of  sugar. 

Fehling's  Test. — As  the  fluid  employed  in  this  test  spoils  on 
keeping,  it  should  be  freshly  prepared  when  required  by  mix- , 
ing  in  equal  proportions  the  following  solutions : — 

First  solution :  Dissolve  34.64  grams  of  pure  cupric  sul- 
phate in  distilled  water,  and  dilute  up  to  500  cubic  centi- 
meters. 

Second  solution:  Dissolve  180  grams  of  pure  Roohelle  salt 
and  70  grams  of  caustic  soda  in  400  cubic  centimeters  of  dis- 


THE    URINE.  101 

tilled  water,  and  heat  to  boiling ;  on  cooling,  make  up  to  500 
cubic  centimeters  with  distilled  water. 

To  about  ten  minims  of  each  solution  in  a  test-tube  add 
about  a  fluid  drachm  of  distilled  water,  and  boil  for  a  few  sec- 
onds ;  if  the  solution  remains  clear,  add  the  suspected  urine 
drop  by  drop,  and  occasionally  heat  the  tube.  If  sugar  is 
abundant,  a  yellowish-red  deposit  will  be  produced.  If  no 
precipitate  falls,  continue  the  addition  of  the  urine  until  an 
equal  volume  has  been  added,  and  allow  to  cool ;  then  if  no 
precipitate  falls,  sugar  is  absent. 

The  Phenyl-hydrazin  Test. — Put  in  a  test-tube  half  filled 
with  water  phenyl  hydrazin  (hydrochlorate)  2  grains  and  so- 
dium acetate  3  grains.  Dissolve  by  heating.  Fill  the  tube 
with  suspected  urine,  and  stand  in  boiling  water  for  twenty 
minutes.  Then  place  in  cold  water.  On  cooling  yellow  radiat- 
ing groups  of  needle-shaped  crystals  of  phenyl-glucosazon  fall, 
which  may  be  detected  under  the  microscope. 

Bottger's  Test. — Add  to  a  couple  of  drachms  of  suspected 
urine  which  is  free  from  albumin  an  equal  volume  of  liquor 
potassse  and  a  few  grains  of  subnitrate  of  bismuth,  and  boil ; 
if  sugar  is  present,  it  will  reduce  the  salt  of  bismuth  to  black 
metallic  bismuth.  Substances  containing  sulphur,  like  albu- 
min, yield  a  similar  black  precipitate. 

The  Fermentation  Test. — Fill  a  four-ounce  bottle  three  parts 
full  of  urine,  and  add  a  fluid  drachm  of  ordinary  yeast,  or  a 
small  portion  of  compressed  yeast,  lightly  cork,  and  subject  to 
a  temperature  of  70°  to  80°  Fahr.  for  ten  or  twelve  hours. 
If  sugar  is  present,  fermentation  results  with  the  evolution  of 
carbon  dioxide,  and  the  specific  gravity  of  the  urine  falls. 

Quantitative  Tests. — Fermentation  test :  Employ  two  bottles 
of  urine,  and  to  the  one  add  the  yeast ;  at  the  end  of  twenty- 
four  hours  take  the  specific  gravity  of  each  specimen.  Every 
degree  lost  in  the  fermented  urine  indicates  a  grain  of  sugar 
to  the  fluidounce. 

Fehling's  Test. — To  one  cubic  centimetre  of  Fehling's  solu- 
tion add  four  cubic  centimetres  of  distilled  water,  and  boil ; 
if  the  solution  still  remains  clear,  add  y^  c.  c.  of  the  urine 
from  a  graduated  pipette,  and  gently  heat.  Continue  the  ad- 
dition of  the  urine,  little  by  little,  until  all  blue  color  has  dis- 


102  DISEASES   OF  THE   KIDNEYS. 

appeared.  If  one  cubic  centimetre  of  urine  has  been  added,  it 
will  have  contained  half  of  one  per  cent,  of  sugar.  If  two 
c.  c.  are  used,  it  will  have  contained  one-quarter  per  cent.  If 
but  a  half  of  a  cubic  centimetre  is  used,  it  will  have  contained 
one  per  cent. 

If  the  specific  gravity  indicates  that  the  amount  of  sugar  is 
great,  dilute  the  urine  with  a  definite  amount  of  water,  and 
estimate  accordingly  (Tyson). 

Albuminuria. — Albumin  in  the  urine. 

Its  Causes. — (1)  All  forms  of  nephritis.  (2)  Congestion  of 
the  kidney,  as  the  result  of  chronic  heart,  lung,  or  liver  dis- 
ease. (3)  Pregnancy.  (4)  Cyclical.  The  urine  may  be  albu- 
minous at  certain  times,  as  after  meals,  heavy  exercise,  bathing, 
or  on  rising  in  the  morning.  (5)  Accidental.  From  the  admix- 
ture of  albuminous  substances  with  the  urine,  as  pus,  semen, 
and  blood.  (6)  Certain  nervous  diseases,  as  epilepsy,  tetanus, 
and  injury  to  the  brain.  (7)  Extreme  anaemia.  (8)  Ingestion 
of  large  amounts  of  albuminous  food. 

Tests  for  Albumin.  Heller's  Test. — Pour  a  small  quantity  of 
colorless  nitric  acid  in  a  test-tube,  and  allow  an  equal  quantity 
of  filtered  urine  to  trickle  from  a  pipette  down  the  sides  of  the 
tube  and  to  come  in  contact  with  the  acid.  If  albumin  is 
present,  a  sharply-defined  white  ring  is  formed  at  the  line  of 
junction. 

Turpentine,  copaiba,  and  other  oleoresins  eliminated  in  the 
urine  yield  similar  rings,  but  the  latter  are  redissolved  on  the 
addition  of  alcohol. 

Uric  acid  produces  an  undefined  pink  ring,  but  it  is  not 
exactly  at  the  line  of  contact,  and  is  redissolved  on  the  ap- 
plication of  heat. 

Johnson\s  Test. — Fill  a  six-inch  test-tube  two-thirds  full  of 
filtered  urine,  and  allow  a  couple  of  drachms  of  a  clear  satu- 
rated solution  of  picric  acid  to  flow  down  the  side  of  the  tube 
and  to  mix  with  the  urine.  Turbidity  indicates  the  presence 
of  albumin,  and  it  increases  on  gently  heating  the  tube  near  its 
mouth.  Certain  substances  in  the  urine,  like  the  alkaloids, 
produce  a  similar  turbidity,  but  this  disappears  en  the  appli- 
cation of  heat. 

Roberts'' s  Nitric  Magnesian  Test. — Very  delicate  and  reliable 


THE  URINE.  103 

The  test-fluid  is  made  by  adding  one  volume  of  strong  nitric 
acid  to  five  volumes  of  a  saturated  solution  of  sulphate  of 
magnesium,  and  is  employed  in  the  same  manner  as  nitric  acid 
in  Heller's  test. 

Acetonuria. — Acetone  results  from  the  metamorphosis  of 
albumin,  and  is  found  in  the  urine  in  many  conditions, 
notably :  (1)  A  trace  in  normal  urine.  (2)  In  Cancer.  (3) 
Febrile  diseases.  (4)  Psychoses.  (5)  It  may  arise  as  a  primary 
condition  (Von  Jaksch).  (6)  In  diabetes  it  is  often  abundant, 
(7)  After  operations. 

Legal' s  Acetone  Test. — To  four  c.c,  of  urine,  rendered  alkaline 
with  liquor  potassse,  add  a  few  drops  of  a  strong  solution  of  sodium 
nitro-prusside.  If  the  red  color  jiroduced  turns  purple  on  the  ad- 
dition of  a  few  drops  of  concentrated  acetic  acid,  acetone  is  present. 

Diaceturia  and  Oxybuturia. — Diacetic  acid  and  oxybutyric 
acid  are  never  found  in  normal  urine,  but  are  found  associated 
with  acetone  in  certain  fevers,  and  especially  in  diabetes. 
Their  decomposition  yields  acetone,  and  they  are  probably  the 
cause  of  diabetic  coma. 

Test  for  Diaoetic  Acid. — Boil  the  urine  and  add  a  solution 
of  ferric  chloride.  If  diacetic  acid  is  present,  a  Burgundy-red 
color  develops. 

Haematuria. — Blood  in  the  urine. 

The  chief  causal  conditions  are :  (1 )  Vicarious  menstrua- 
tion, (2)  Traumatism  applied  to  any  part  of  the  genito- 
urinary tract.  (3)  General  blood  dyscrasia,  as  in  the  specific 
fevers,  purpura,  malaria,  scurvy,  etc.  (4)  Congestion  of  the 
kidney  from  chronic  heart,  lung,  or  liver  disease.  (5)  Acute 
inflammation  of  any  part  of  the  genito-urinary  tract.  (6)  Stone 
in  tiie  genito-urinary  tract.  (7)  Varicose  veins  at  the  neck  of 
the  bladder.  (8)  It  may  occur  paroxysmally  without  obvious 
cause.  (9)  Parasites  in  the  genito-urinary  tract,  as  the  Filaria 
sanguinis  hominis  and  the  Distoma  haematobium.  (10)  Tu- 
mors and  tubercle  of  the  kidney  and  bladder. 

Diagnosis. — By  the  color  of  the  urine  and  by  microscopic 
and  spectroscopic  examination. 

Heller's  Test. — Boil  the  urine  with  a  solution  of  caustic 
potash :  phosphates  are  precipitated,  which  assume  a  red 
color  from  the  freed  hsematin. 


104  DISEASES   OF   THE   KIDNEYS. 

Source  of  the  Hemorrhage.  Urethra. — The  urine  first  passed 
is  bloody,  and  the  other  symptoms  point  to  tlie  urethra. 

Bladder.  —  Bleeding  often  at  the  end  of  micturition,  and 
other  symptoms,  point  to  the  bladder. 

Kidney. — Blood  intimately  mixed.  There  may  be  blood- 
casts  or  clots,  and  the  other  symptoms  point  to  the  kidneys. 

Haemoglobinuria. — Blood-pigment  in  the  urine. 

The  chief  causal  conditions  are:  (1)  Blood  disintegration 
from  the  specific  fevers,  scurvy,  purpura,  malaria,  etc.  (2) 
Absorption  of  internal  hemorrhagic  effusions.  (3)  It  follows 
transfusion  of  blood.  (4)  Paroxysmally,  without  obvious 
cause.  (5)  Poisons,  such  as  carbolic  acid,  potassium  chlorate, 
phosphorus,  etc. 

Indicanuria. — Indican  is  a  colorless  compound  resulting 
from  the  decomposition  of  albuminous  substances  in  the  small 
intestine,  and  by  oxidation  is  converted  into  indigo. 

It  occurs  (1)  Frequently  in  health.  (2)  From  undue  reten- 
tion of  material  in  the  small  intestine,  as  in  peritonitis,  intes- 
tinal obstruction,  and  obstinate  constipation.  (3)  In  wasting 
diseases.     (4)  Purulent  inflammations.     (5)  Asiatic  cholera. 

Test  for  Indican. — Mix  equal  volumes  of  urine  and  fresh 
hydrochloric  acid,  and  add,  drop  by  drop,  a  fresh  concen- 
trated solution  of  chloride  of  lime  (5  to  1000).  Indican  is 
indicated  by  the  appearance  of  an  indigo-blue  color. 

Choluria. — Bile  in  the  urine.  Bile-pigment  is  found  in  the 
urine  in  all  forms  of  jaundice. 

Bile-acids  in  the  urine  indicate  hepatogenous  jaundice,  but 
their  absence  in  jaundice  is  no  proof  that  the  latter  is  hsemoto- 
genous  in  origin. 

Gmellins  Test  for  Bile-pigment. — Allow  a  few  drops  of  urine 
and  a  few  drops  of  fuming  nitric  acid  to  come  together  on  a 
white  plate.  If  bile  is  present,  there  will  be  an  iridescent  play 
of  colors — green,  blue,  violet,  and  red — at  the  line  of  contact. 

PettenkoJfe7''s  Test  for  Bile-acids. — Add  a  few  grains  of  cane- 
sugar  and  a  drop  of  sulphuric  acid  to  the  suspected  urine  in  a 
test-tube ;  heat  gently,  and  if  bile-acids  are  present  a  violet- 
red  color  is  produced. 

Chyluria. — Chyle  in  the  urine.  It  produces  a  milky  tur- 
bidity which  gradually  rises  to  the  top  of  the  urine  in  the  form 


RENAL   HYPEREMIA.  105 

of  pellicles  of  finely-divided  fat.  Its  chief  causes  are  :  (1) 
Injury  to  the  lymphatic  ducts.  (2)  Pregnancy.  (3)  Obstruc- 
tion of  the  lymphatic  ducts  by  the  Filaria  sanguinis  hominis, 
a  thread-worm  most  coniQionly  met  with  in  the  tropics. 

P3niri3.' — Piis  in  the  urine.  It  results  (1)  from  suppura- 
tive inflammation  of  any  part  of  the  genito-urinary  tract,  and 
(2)  from  the  rupture  of  abscesses  into  the  tract. 

It  appears  as  a  dull,  greenish-yellow  precipitate  which  is 
converted  into  a  clear  gelatinous  mass  by  the  addition  of  liquor 
potassse.     It  can  always  be  detected  by  the  microscope. 

Source. — When  pus  is  from  the  kidney  it  is  intimately  mixed 
with  the  urine,  the  latter  has  an  acid  or  neutral  reaction,  and 
the  associated  symptoms  point  to  the  kidneys. 

When  the  pus  is  from  the  bladder  it  is  not  so  intimately 
mixed  with  the  urine ;  the  latter  is  usually  alkaline  in  reaction, 
and  the  associated  symptoms  point  to  the  bladder. 

REI^AL  HYPEREMIA. 

Varieties. — (1)  Active  hypersemia,  and  (2)  passive  hy- 
perajmia. 

Active  Hypersemia. 

(Acute  Congestion.) 

Causes. — (1)  Exposure  to  cold  when  the  body  is  over- 
heated. (2)  Eruptive  fevers.  (3)  Poisons,  as  the  stimulating 
diuretics.     (4)  Pregnancy. 

The  same  cause  aggravated  would  produce  acute  nephritis. 

Pathology. — The  kidney  is  swollen,  of  a  deep  red  color, 
and  bleeds  freely  on  section.  Microscopic  examination  reveals 
cloudy  swelling  of  the  renal  epithelium. 

Symptoms. — Pain  over  the  loins.  The  urine  is  dark, 
scanty,  of  high  specific  gravity,  and  may  contain  a  trace  of 
albumin,  a  few  hyaline  casts,  and  some  free  blood. 

Prognosis. — If  the  cause  can  be  removed,  the  prognosis  is 
favorable. 

Treatment. — -Absolute  rest.  Wet  cups  or  warm  fomenta- 
tions over  the  loins.  Liberal  use  of  water.  Saline  laxatives. 
Encourage  sweating  by  the  vapor  bath  or  small  doses  of  pilo- 


106  DISEASES    OF    THE   KIDNEYS. 

carpi ne.    The  infusion  of  digitalis  may  be  used  to  increase  the 
quantity  of  urine. 

Passive  Hypersemia. 

(Chronic  Congestion.) 

Etiology. — (1)  Causes  which  obstruct  the  general  circula- 
tion, as  chronic  heart,  lung,  and  liver  disease.  (2)  Pressure 
of  tumors  on  the  renal  veins.  (3)  Rarely  thrombosis  of  the 
renal  veins. 

Pathology. — The  kidney  is  swollen  and  of  a  bluish-red 
color,  and  later  becomes  hard  from  an  overgrowth  of  con- 
nective tissue  (cyanotic  induration).  In  advanced  cases  the 
renal  epithelium  is  fatty. 

Symptoms. — Sensation  of  weight  over  the  loins.  The  urine 
is  usually  diminished,  but  is  rarely  increased  in  quantity. 
Free  blood,  a  little  albumin,  and  occasionally  a  few  narrow 
hyaline  casts  are  found. 

Diagnosis. — The  comparative  absence  of  albumin  and 
casts,  the  absence  of  dropsy  and  ursemic  symptoms,  and  the 
presence  of  urea  in  normal  amount  will  separate  congestion 
from  nephritis. 

Prognosis. — Depends  on  the  cause. 

Treatment. — Rest.  Light  diet.  Dry  cups  to  the  loins. 
The  use  of  diuretics  when  the  urine  is  scanty.  The  following 
tonic  diuretic  pill  may  be  of  service : — 

^   Quininse  sulph.,  gr.  xxx  ; 

Pulv.  digitalis,  gr.  xxx  ; 

Pulv.  scillse,  gr.  xxx  ; 

Ext.  nucis  vomicse,  gr.  v  ; 

Pulv.  ferri  carb.,  gr.  xxx.— M      (Pepper.) 
Div.  in  pil.  Ko.  xxx. 
Sig. — One  pill  every  three  hours. 

UREMIA. 

Definition. — The  name  applied  to  a  group  of  symptoms 
resulting  from  the  retention  of  toxic  materials  in  the  blood 
which  should  have  been  eliminated  by  the  kidneys. 

Symptoms. — It  may  develop  slowly  or  abruptly,  and  may 
manifest  any  of  the  following  phenomena:  Headache,  ver- 
tigo, delirium,  epileptiform  convulsions,  coma,  sudden  blind- 


ACUTE   NEPHRITIS.  107 

uess  (unassociated  with  any  retinal  change),  and  transient 
paralysis  from  congestion  or  oedema  of  the  brain  or  cord. 

Pulmonary  Symptoms. — Dyspnoea,  (ursemic  asthma),  Cheyne- 
Stokes  breathing. 

Abdominal  Symptoms. — Hiccough,  obstinate  vomiting,  and 
purging. 

General  Symptoms. — The  skin  is  dry;  the  breath  has  a 
urinous  odor;  the  urine  is  scanty  and  deficient  in  urea.  The 
pulse  is  slow  and  full,  and  the  temperature  subnormal ;  but 
during  convulsions  the  temperature  may  rise  and  the  pulse 
become  rapid  and  feeble. 

Diagnosis. — The  various  manifestations  may  be  recognized 
as  ursemic  by  the  history,  the  temperature,  the  odor  of  the 
breath,  the  high  arterial  tension,  the  accentuated  second  sound 
of  the  heart,  the  presence  of  casts  and  albumin  in  the  urine, 
and  by  the  absence  of  any  other  cause. 

Prognosis. — Grave,  but  always  guarded,  for  recovery  is 
possible  after  the  most  serious  manifestations. 

Treatment. — The  poison  must  be  eliminated  promptly. 
Croton  oil  (1  to  2  drops  in  a  little  glycerin)  or  elaterium  (gr.  ^) 
should  be  given  to  promote  catharsis.  Free  diaphoresis  may 
be  secured  by  hot-air  or  vapor  baths,  and  the  subcutaneous 
injection  of  pilocarpine  (gr.  ^  to  4).  When  the  patient  is  not 
too  weak  venesection  is  of  great  service.  The  subcutaneous 
administration  of  a  sterilized  normal  salt  solution  is  highly 
recommended.  Convulsions  may  be  controlled  by  inhalations 
of  chloroform,  and  the  exhibition  by  the  rectum  of  chloral 
hydrate  (gr.  xxx  to  xl).  Some  advise  the  use  of  morphine, 
but  in  the  convulsions  of  chronic  interstitial  nej)hritis  it  must 
be  used  with  extreme  caution. 


ACUTE  NEPHRITIS. 

(Acute  Bright' s  Disease,  Acute  Tubular  Nephritis,  Acute  Desqua- 
mative Nephritis,  Acute  Parenchymatous  Nephritis,  Acute 
Catarrhal  Nephritis.) 

Definition. — An  acute  inflammatory  process  involving 
more  or  less  the  whole  kidney,  but  especially  affecting  the 
epithelium  of  the  tubules  and  glomeruli. 


108  DISEASES   OF   THE   KIDNEYS. 

Etiology. — (1)  Exposure  to  cold  and  wet.  (2)  The  spe- 
cific fevers,  especially  scarlet  fever.  (3)  Poisons  which  are 
eliminated  through  the  kidneys,  as  cantharides,  turpentine,  etc. 
(4)  Pregnancy. 

Pathology. — The  kidney  is  swollen  and  the  capsule  non- 
adherent. At  first  the  organ  is  bright  red  in  color ;  it  soon, 
however,  becomes  pale  and  mottled  in  appearance,  although 
the  Malpighian  tufts  still  retain  their  deep  red  tint. 

Histology. — The  epithelium  of  the  tubules  and  glomeruli 
is  the  seat  of  cloudy  swelling  and,  later,  of  fatty  degeneration. 
Desquamated  epithelium,  blood-corpuscles,  and  an  albuminous 
exudate  block  up  the  tubules.  The  capillaries  are  dilated, 
their  walls  degenerated,  and  bloody  extravasations  are  not  in- 
frequently seen.  The  interstitial  tissue  is  more  or  less  infil- 
trated with  leucocytes. 

Symptoms. — Moderate  fever  and  its  associated  symptoms ; 
dull  lumbar  pain ;  nausea  and  vomiting ;  dropsy,  beginning 
in  the  face  and  becoming  general ;  rapid  anaemia.  Ursemic 
symptoms  may  develop  at  any  time. 

The  Urine. — Scanty  and  at  times  suppressed.  It  is  smoky 
in  appearance,  of  high  specific  gravity,  rich  in  albumin,  and 
throws  a  heavy  sediment,  which  contains  hyaline,  blood,  and 
epithelial  casts,  and  free  blood  and  epithelial  cells. 

Diagnosis. — As  the  general  symptoms  are  often  slight,  the 
diagnosis  must  rest  on  the  examination  of  the  urine.  The 
history,  and  the  absence  in  the  urine  of  wide,  highly  fatty 
casts,  will  serve  to  distinguish  acute  nephritis  from  an  acute 
exacerbation  of  chronic  jjarenchymatous  nephritis. 

Prognosis. — Guardedly  favorable.  It  may  kill  by  exhaus- 
tion, urseniia,  or  dropsy.     It  may  become  chronic. 

Treatment. — Absolute  rest  in  bed  until  albumin  has  dis- 
appeared from  the  urine.  Milk  is  the  best  food  ;  but  butter- 
milk, gruels,  and  light  broths  are  admissible.  The  free  use  of 
water  should  be  encouraged.  Dry  or  wet  cups,  or  hot  fomen- 
tations should  be  applied  to  the  loins.  To  secure  vicarious 
action  of  the  skin  vapor  baths  or  small  doses  of  pilocarpine 
(gr.  \  to  yig)  may  be  employed.  Concentrated  saline  draughts, 
made  of  Rochelle  or  Epsom  salts,  may  be  given  to  secure 
watery  discharges  from  the  bowels.     Compound  jalap  powder 


CHRONIC    PARENCHYMATOUS    NEPHRITIS.  109 

(gr.  xx),  or  elaterlum  (gr.  ^)  may  be  substituted  for  the  saline. 
Stimulating  diuretics  should  be  avoided,  and  diuresis  encour- 
aged by  alkaline  waters  and  infusion  of  digitalis.  Uraemia 
will  call  for  its  appropriate  treatment. 

Severe  cases  in  pregnancy  will  require  the  induction  of 
abortion  or  premature  labor. 

Marked  effusions  into  the  serous  cavities  will  sometimes 
demand  aspiration.  Convalescence  should  be  protracted,  and 
the  resulting  anaemia  will  call  for  some  preparation  of  iron, 
such  as  Basham's  mixture. 

CHRONIC  PARENCHYMATOUS  NEPHRITIS. 

(Chronic  Catarrhal  Nephritis,  Large   White  Kidney.) 

Etiology. — (1)  It  may  result  from  acute  nephritis,  (2)  It 
may  be  chronic  from  the  beginning.  Male  sex,  adult  life, 
frequent  exposure  to  cokl  and  wet,  alcoholism,  congestion  from 
lieart  disease,  and  syphilis  are  predisposing  factors. 

Pathology. — In  the  first  stage  the  kidney  is  large  and 
pale-yellow  in  color  ;  the  pallor  depends  on  angemia  and  fatty 
degeneration  ;  the  tubes  are  filled  with  fatty  epithelium  and 
casts ;  there  is  always  some  overgrowth  of  the  interstitial  con- 
nective tissue. 

In  the  second  stage  the  organ  is  small,  pale  in  color,  its  sur- 
face rough,  and  its  capsule  somewhat  adherent.  *  The  reduced 
size  depends  on  destruction  of  the  renal  epithelium  and  the 
contraction  of  the  overgrown  connective  tissue. 

Symptoms.  —  As  it  usually  begins  as  a  chronic  affection, 
the  following  symptoms  slowly  manifest  themselves :  Pro- 
gressive loss  of  flesh  and  strength  ;  marked  anaemia  ;  gastro- 
intestinal disturbances ;  dropsy,  often  first  noted  in  the  face 
on  rising  in  the  morning ;  increased  arterial  tension ;  some 
hypertrophy  of  the  left  ventricle,  so  that  the  second  sound  at 
the  aortic  cartilage  is  accentuated.  Uraemic  symptoms  may 
develop  at  any  time. 

The  Urine. — Usually  diminished,  although  it  is  frequently 
normal  in  color  and  in  appearance.  It  is  highly  albuminous, 
and  throws  down  an  abundant  sediment,  which  contains  hya- 
line,  fatty,  and  granular  casts,  and  fatty  epithelial  cells. 


110  DISEASES    OF    THE    KIDNEYS. 

Complications. — These  are  Dumerous  and  often  suggest 
the  diagnosis.  The  most  common  are  nrsemia,  extensive 
dropsy  into  the  tissues  or  serous  cavities,  latent  inflammations 
of  the  serous  membranes,  valvular  heart  disease,  albuminuric 
retinitis,  apoplexy,  and  acute  exacerbations. 

Prognosis. — Unfavorable.  In  the  early  stages  recovery 
sometimes  results.  The  duration  is  from  a  few  months  to 
several  years. 

Treatment.  —  The  treatment  is  largely  dietetic  and 
hygienic.  Residence  in  a  dry,  warm,  and  equable  climate 
may  prolong  life  or  effect  a  cure.  Rest  is  an  essential  element 
in  the  treatment.  The  underclothing  should  be  woollen  or 
silk.  The  diet  should  be  non-nitrogenous,  and  in  severe  cases 
an  absolute  milk  diet  may  be  of  extreme  value.  The  bowels 
should  be  kept  active  by  natural  mineral  waters  or  saline 
laxatives.  When  the  urine  is  scanty,  digitalis,  caffeine,  or 
strontium  lactate  (gr.  xv-xxx)  may  prove  efficient.  Basham's 
mixture  may  be  employed  as  a  chalybeate  and  a  diuretic. 

In  excessive  dropsy  promote  catharsis  by  Epsom  salts  in 
concentrated  solution,  or  by  compound  jalap  powder;  and 
promote  diaphoresis  by  the  hot-air  bath,  or  by  pilocarpine. 

Niemeyer's  pill  (page  90)  or  the  following  combination  is 
often  very  efficient  in  troublesome  dropsy  : — 

R     Spartein.  sulph.,  gr.  vj ; 

Caffein.  citrat.,  gr.  xxx  ; 

Lithii  benzoat.,  3j.-^M. 
Ft.  chart.  No.  xii. 
Sig. — One  powder  every  three  hours. 

Acute  exacerbations  should  be  treated  as  primary  attacks  of 
acute  nephritis. 

CHRONIC  INTERSTITIAL  NEPHRITIS. 

(Red  Granular  Kidney,  Contracted  Kidney,  Gouty  Kidney.) 

Definition. — A  chronic  inflammatory  condition  of  the 
kidney  characterized  by  areduction  in  its  size,  due  to  an  over- 
growth and  subsequent  contraction  of  its  connective-tissue 
elements,  and  invariably  associated  with  general  arterial  scle- 
rosis and  cardiac  hypertrophy. 


CHRONIC    INTERSTITIAL    NEPHJUTIS.  Ill 

Etiology. — It  may  be  secondary  to  parenchymatous 
nephritis,  or  result  from  the  passive  congestion  of  chronic 
heart  disease ;  but  generally  it  arises  as  a  primary  condition, 
and  results  from  the  causes  which  predispose  to  sclerosis  in 
other  organs,  viz.,  middle  life,  male  sex,  syphilis,  the  gouty 
diathesis,  chronic  alcoholism,  and  chronic  mineral  poisoning, 
as  from  lead. 

Pathology. — The  kidneys  are  small,  and  red  in  color. 
The  surface  is  granular,  and  the  capsule  adherent.  The  or- 
gan is  firm,  cuts  with  difficulty,  and  on  section  often  reveals 
small  cysts  or  calcareous  deposits.  The  cortical  substance  is 
greatly  reduced  in  thickness.  Microscopic  examination  shows 
an  overgrowth  of  connective  tissue  which  has  contracted,  nar- 
rowed the  lumen  of  the  tubules,  and  interfered  with  the 
nutrition  of  the  epithelium,  and  as  a  result  the  latter  may 
show  fatty  degeneration  with  desquamation.  The  arteries 
throughout  the  body  reveal  fatty  degeneration  of  the  media 
and  an  overgrowth  of  connective  tissue  in  the  intima  (arterio- 
sclerosis), and  from  the  resistance  thus  offered  hypertrophy  of 
the  heart  has  resulted. 

Symptoms. — A  slow  loss  of  flesh  and  strength  with  pixj- 
gressive  aneemia.  Gastric  disturbances  are  very  common. 
The  arteries  are  rigid,  and  the  pulse  is  of  high  tension,  so  that 
the  second  sound  of  the  heart  is  accentuated  at  the  aortic  carti- 
lage. 

Palpitation  of  the  heart  is  often  noted.  Dyspnoea  is  a 
prominent  symptom,  and  may  result  from  heart-weakness, 
uraemia,  or  oedema  of  the  lungs.  Headache,  vertigo,  and 
insomnia  often  result  from  disturbed  circulation,  and  dimness 
of  vision  from  albuminuric  retinitis. 

Dropsy  is  often  absent,  or  is  slight  and  appears  late  in  the 
disease. 

The  urine :  Increased  in  quantity,  pale  in  color,  and  of  low 
specific  gravity  (1010-1005),  and  contains  but  a  trace  of  albu- 
min and  a  few  narrow  hyaline  casts. 

Complications.  —  Albuminuric  retinitis,  valvidar  heart 
disease,  apoplexy  resulting  from  the  weakened  arteries  and 
large  heart,  urgemia,  latent  inflanmiations  of  serous  mem- 
branes, pneumonia,  and  bronchitis. 


k 


112  DISEASES    OF   THE    KIDNEYS. 

Diagnosis. — The  arterial  changes,  casts  in  the  urine, 
uraemic  symptoms,  and  the  absence  of  poikilocytosis  will  serve 
to  distinguish  chronic  nephritis  from  pernicious  ancemia. 

Chronic  parenchymatous  nephritis  usually  occurs  earlier  in 
life,  lacks  much  arterial  change,  produces  considerable  dropsy, 
and  urine  that  is  rich  in  albumin  and  tube-casts. 

Prognosis. — It  is  incurable,  but  may  last  many  years,  and 
under  favorable  conditions  comparative  comfort  may  be  ob- 
tained. 

Treatment. — The  dietetic  and  hygienic  treatment  is  the 
same  as  in  chronic  parenchymatous  nephritis.  Frequent  bath- 
ing with  friction  of  the  skin  should  be  encouraged,  and  the 
bowels  kept  regular  by  alkaline  waters. 

Absorbents,  like  the  bichloride  of  mercury  and  iodide  of 
potassium,  are  of  little  value.  If  the  stomach  will  bear  it,  iron 
will  be  of  service.  Digitalis,  caffeine,  and  strychnine  will  be 
very  useful  when  the  heart  weakens.  Nitroglycerin,  in  one 
minim  doses,  gradually  increased,  has  been  recommended  for 
the  high  arterial  tension. 

AMYLOID  KIDNEY. 

(Waxy  Kidney,  Lardaceous  Kidney.) 

Etiology. — (1)  Prolonged  suppuration,  particularly  in 
bone  disease.  (2)  Tuberculosis.  (3)  Syphilis.  (4)- Malarial 
cachexia. 

Pathology. — The  kidney  is  large  and  pale,  and  on  sec- 
tion presents  a  waxy,  translucent  appearance. 

Lugol's  solution  of  iodine  strikes  a  mahogany-red  color 
with  the  amyloid  material. 

On  microscopic  examination,  the  walls  of  the  bloodvessels, 
particularly  those  of  the  Malpighian  tufts,  are  found  thickened, 
and  infiltrated  with  a  homogeneous  wax-like  material,  which 
turns  red  when  treated  with  a  weak  solution  of  gentian-violet. 

Parenchymatous  and  interstitial  changes  are  always'  noted. 
Other  organs,  especially  the  liver  and  spleen,  are  similarly 
affected. 

Symptoms. — Loss  of  flesh  and  strength.  Math  great  pallor 
and   moderate  dropsy.      Ursemic  symptoms  are  uncommon. 


RENAL   CALCULUS.  113 

The  liver  and  spleen  are  often  much  enlarged  from  the  same 
degeneration. 

The  Urine. — Usually  increased  in  amount,  pale  in  color,  and 
contains  considerable  albumin  and  wide  hyaline  and  granular 
casts. 

Diagnosis. — The  history,  the  enlarged  liver  and  spleen, 
and  the  increased  amount  of  urine  containing  considerable 
albumin  suggest  the  diagnosis. 

Prognosis. — When  not  advanced,  and  the  cause  can  be 
removed,  the  disease  may  be  arrested.  As  a  rule,  the  prog- 
nosis is  decidedly  unfavorable. 

Treatment. — The  primary  disease  will  claim  attention. 
In  bone  disease,  surgical  interference  may  be  requisite.  In 
syphilis,  iodide  of  potassium  and  mercurials  will  be  indicated. 
In  malarial  cachexia,  iron,  quinine,  and  arsenic  should  be  em- 
ployed.    Tuberculosis  will  call  for  its  appropriate  remedies. 

The  treatment  of  the  morbid  condition  is  hygienic  and 
dietetic.  Alterative  tonics,  like  the  iodide  of  iron,  may  prove 
beneficial  in  some  cases. 


RENAL  CALCULUS. 

(Nephrolithiasis,  Renal  Gravel.) 

Definition. — A  precipitated  urinary  concretion  found  in 
the  kidney. 

Etiology. — (1)  Male  sex.  (2)  Heredity.  (3)  Mal-assimi- 
lation.  (4)  Inflammation  of  the  pelvis  of  the  kidney.  Doubt- 
less mucus  or  desquamated  epithelium  forms  the  nucleus  upon 
which  the  stone  is  built. 

Varieties. — (1)  Uric  acid.  This  may  be  passed  as  sand, 
or  form  large  reddish-brown  stones  (2)  Oxalate  of  lime. 
This  forms  a  very  hard,  dark,  and  uneven  stone  (mulberry 
calculus).  (3)  Phosphates.  These  are  composed  of  phosphate 
of  lime,  and  ammonio-magnesium  phosphate,  and  are  soft, 
mortar-like  in  appearance,  and  are  often  deposited  on  other 
calculi.     (4)  Xanthine  and  cystine  are  rare  concretions. 

Events. — (1)  A  stone  may  remain  latent  indefinitely.  (2)  It 
may  pass  out,  with  or  without  the  symptoms  of  colic.     (3)  It 


114  DISEASES    OF    THE    KIDNEYS. 

excites  pyelitis,  and  sometimes  abscess  of  the  kidney.  (4)  It 
may  obstruct  tiie  ureter  and  produce  hydro-nephrosis  or  pyo- 
nephrosis. (5)  It  may  excite  perinephritis,  and  may  perforate 
in  other  organs. 

Symptoms  of  Renal  Colic. — Sudden  onset,  with  sharp 
pain,  starting  in  the  back  and  radiating  down  the  ureter  into 
the  penis,  testicle,  or  thigh.  There  may  be  retraction  of  the 
testicle  on  the  affected  side. 

The  symptoms  of  intense  pain  are  often  present,  viz : 
pallor,  cold  sweats,  weak  pulse,  and  reflex  vomiting. 

The  urine  subsequently  passed  may  contain  the  stone;  or, 
as  a  result  of  irritation,  pus,  blood  and  desquamated  pelvic 
epithelium.  An  attack  may  last  from  a  few  moments  to 
several  hours. 

Diagnosis.  Biliary  and  Renal  Colic. — In  the  former  the 
pain  runs  from  the  right  hypochondriac  region  to  the  right 
shoulder;  there  is  often  jaundice,  and  the  urine  is  negative, 
w^hile  the  stools  may  contain  the  stone. 

Prognosis. — In  view  of  the  complications  the  prognosis 
must  be  guarded. 

Treatment.  The  Attack. — Morphine  and  atropine  should 
be  employed  hypodej-mically,  and  warm  poultices  applied  to 
the  loins.  The  free  use  of  water  should  be  encouraged.  In 
severe  cases  chloroform  or  ether  may  be  inhaled  in  sufficient 
quantity  to  obtund  the  sensibility  of  the  patient. 

The  Interval. — When  symptoms  persist,  regulate  the  diet, 
and  put  the  patient  under  good  hygienic  conditions.  When 
tlie  reaction  of  the  urine  indicates  an  acid  stone,  the  salts  of 
lithium  or  the  vegetable  salts  of  potash  may  be  employed  in 
large  doses,  over  long  periods.  A  drachm  of  the  citrate  of 
potassium  or  five  to  ten  grains  of  the  carbonate  of  lithium 
may  be  given,  well  diluted,  several  times  a  day.  The  natural 
mineral  waters  are  of  some  value.  The  Buffalo  lithia  water 
may  be  employed  for  this  purpose,  and  its  palatableness  and 
efficiency  may  be  increased  by  the  addition  of  a  teaspoonful 
of  some  effervescing  preparation  of  lithium  to  each  potation. 

When  an  alkaline  stone  is  indicated,  benzoic  acid  or  boric 
acid  may  be  employed  in  a  similar  manner. 

In  severe  and  persistent  cases  the  stone   may  be  excised 


PYELITIS.  115 

(nephro-lithotomy) ;  and  if  the  operation  should  reveal  a 
badly-damaged  kidney,  its  removal  (nephrectomy)  would  be 
indicated. 

PYELITIS. 

(Pyelonephritis,  Pyonephrosis.) 

Definition. — Inflammation  of  the  pelvis  of  the  kidney. 

Etiology. — (1)  It  may  result  from  stone  in  the  pelvis  of 
the  kidney  (calculous  pyelitis).  (2)  It  may  be  secondary  to 
urethritis  or  cystitis  extending  upwards  through  the  ureters. 
(3)  It  may  follow  pregnancy  or  the  specific  fevers.  (4)  Morbid 
growths,  such  as  tubercle  or  cancer.  (5)  Toxic  doses  of  the 
stimulating  diuretics  (copaiba,  cantharides,  etc.).  (6)  It  is 
rarely  idiopathic  from  exposure  to  cold  and  wet. 

Patholouy. — The  mucous  membrane  is  swollen,  injected, 
and  covered  with  a  tenacious  secretion  composed  of  mucus, 
pus,  and  desquamated  epithelium.  Severe  cases  may  lead  to 
dilatation  of  the  pelvis,  Bright's  disease,  or  suppurative 
nephritis. 

Symptoms. — Moderate  fever  and  its  associated  phenomena. 
In  suppurative  nephritis  the  fever  may  be  irregular  and  asso- 
ciated with  hectic  or  typhoid  symptoms.  There  is  pain  and 
sometimes  tenderness  over  the  kidneys.  The  urine  is  turbid, 
acid  in  reaction,  and  on  standing  throws  down  a  sediment  con- 
taining considerable  mucus,  pus-corpuscles,  pelvic  epithelium, 
and  blood-corpuscles.  The  pus  and  blood  render  the  urine 
slightly  albuminous. 

Diagnosis. — The  absence  of  much  albumin,  of  tube-casts, 
and  dropsy  exchide  nepjij-ifis. 

Cystitis!  may  be  detected  by  the  absence  of  lumbar  pains 
and  of  acid  urine,  and  by  the  presence  of  freqiieut  and  painful 
micturition  and  alkaline  urine  containing  vesical  epithelium. 

PerinephritiG  abscess  is  also  associated  with  lumbar  pain 
and  hectic  fever ;  but  in  addition  there  is  often  oedema  over 
the  lumbar  region,  and  the  urine  may  be  normal. 

Sharp  pain  over  the  kidney,  increased  by  jarring  movements, 
and  reflected  down  the  ureters,  and  the  presence  of  much  blood 
in  the  urine  point  to  calculous  pyelitis. 


116  DISEASES   or   THE   KIDNEYS. 

Tuberculous  pyelitis  may  be  recognized  by  the  history,  by 
the  presence  of  tubercle  in  other  organs,  and  by  tubercle"  bacilli 
in  the  urine. 

Pyelitis  secondary  to  cystitis  is  recognized  by  the  history. 

Prognosis. — Depends  on  the  cause.  Mild  forms  resulting 
from  pregnancy,  specific  fevers,  or  exposure  to  cold,  usually 
recover  in  a  few  weeks.  The  tuberculous  and  suppurative 
varieties  are  unfavorable. 

Treatment. — Depends  on  the  cause.  Calculous  pyelitis 
will  require  the  treatment  indicated  for  renal  calculus.  In 
simple  pyelitis  keep  the  patient  at  rest,  restrict  the  diet  to  light 
food,  preferably  to  milk,  apply  warm  poultices  locally,  use 
alkaline  diluents  and  some  sedative  mixture,  as  the  following  : — 

^   Potass,  broniid., 

Sodii  bicarb.,  aa  gr.  clx  ; 
Ext.  belladonniB,  gr.  iv ; 
Ext.  buchu,  3j  ; 

Syr.  sarsp.  comp.,  q.  s.  ad  fsiv. — M.    (Pepper.) 
Sig. — Tablespoonful  three  times  a  day. 

In  pyelitis  following  cystitis,  treat  the  latter  locally,  and 
use  stimulating  diuretics,  like  eucalyptus,  sandalwood,  and 
copaiba. 

HYDRONEPHROSIS. 

Definition. — Dilatation  of  the  pelvis  of  the  kidney,  with 
the  accumulation  of  a  watery  fluid,  resulting  from  obstruction. 

Etiology. — (1)  Congenital  stricture  of  the  ureter.  (2)  Im- 
paction of  a  calculus  in  the  ureter.  (3)  Abdominal  tumors 
compressing  the  ureter.  (4)  Tumors  growing  within  the 
urinary  passages.  (5)  An  inflammatory  stricture  of  the  ureter 
or  urethra.  . 

Pathology. — The  pelvis  reveals  all  grades  of  distention. 
In  extreme  cases  it.  may  contain  several  quarts  of  fluid,  which 
is  at  first  urinous,  but  later  thin  and  watery.  There  is  more 
or  less  atrophy  of  the  renal  tissue. 

Symptoms. — Slight  distention  yields  no  symptoms.  In 
other  cases  a  tumor  slowly  develops  in  the  region  of  the 
affected    kidney.      On    palpation  it   is   elastic,  and   perhaps 


FLOATING    KIDNEY.  117 

fluctuating  ;  on  percussion,  dull ;  and  on  aspiration  it  yields  a 
clear  fluid,  which  usually  contains  urea  and  uric  acid. 

Diagnosis. — This  will  be  based  on  the  history,  the  exclu- 
sion of  other  abdominal  enlargements,  and  the  chemical 
analysis  of  the  fluid  obtained  by  aspiration. 

Peogjstosis. — Usually  unfavorable.  When  it  is  unilateral, 
and  the  other  kidney  secretes  a  normal  amount  of  urine,  con- 
taining a  normal  amount  of  urea,  the  prognosis  is  guardedly 
favorable. 

Treatment. — When  the  distention  is  moderate  the  treat- 
ment is  expectant.  When  the  sac  is  large,  aspirate ;  and  if 
re-accumulation  is  rapid,  establish  a  renal  fistula  or  remove 
the  organ. 

FLOATING  KIDNEY. 

(Movable  Kidney.) 

Definition. — A  distinctly  mobile  condition  of  the  kidney, 
dependent  upon  a  relaxation  of  the  tissues  which  surround  it. 

Etiology.— (1)  Female  sex.  (2)  Middle  life.  (3)  Rapid 
emaciation  leading  to  the  absorption  of  the  perinephritic  fat. 

(4)  A  congenital  relaxed  condition  of  the  perinephritic  tissues. 

(5)  Muscular  exertion.     (6)  Repeated  pregnancies. 
Symptoms. — The  right  kidney  is  the  one  usually  affected, 

probably  from  its  relation  to  the  liver,  which  moves  during 
the  respiratory  acts.  The  kidney  may  be  found  in  any  part 
of  the  abdomen,  as  a  movable  tumor,  reniform  in  shape, 
somewhat  tender  to  the  touch,  and  rarely  imparting  the  pulsa- 
tion of  the  renal  artery. 

There  may  be  no  subjective  symptoms,  but  a  sense  of  un- 
easiness and  attacks  of  neuralgic  pain  are  often  noted.  At 
times  the  kidney  may  become  swollen  and  very  tender,  pro- 
bably from  twisting  of  the  renal  vessels  inducing  engorgement 
of  the  organ.  Emotional  disturbances  are  often  excited  by 
the  condition. 

Diagnosis. — The  reniform  shape  of  the  tumor,  its  free 
mobility,  its  stationary  size,  the  lessened  resistance  on  percus- 
sion over  the  renal  region  of  the  affected  side,  and  the  absence 
of  cachexia  will  serve  to  diagnose  a  floating  kidney  from  other 
abdominal  tumors. 


118  DISEASES    OF   THE    KIDNEYS. 

Treatment. — In  many  cases,  a  regulated  diet,  the  avoid- 
ance of  undue  exertion,  and  the  use  of  a  broad  binder  applied 
firmly  to  the  abdomen  will  be  the  only  treatment  required. 
When  the  symptoms  persist  the  kidney  may  be  stitched  in 
its  normal  place  (nephrorrhaphy) ;  and  if  this  treatment  fails 
the  offending  organ  may  be  removed  (nephrectomy). 

TUBERCULOSIS   OF  THE  KIDNEY. 

Etiology. — The  etiology  of  renal  tuberculosis  is  that  of 
tuberculosis  in  general.  Males  are  more  frequently  attacked 
than  females.  The  majority  of  cases  are  encountered  between 
the  ages  of  twenty  and  forty  years. 

Pathology. — Two  forms  of  renal  tuberculosis  have  been 
recognized — the  miliary  and  the  caseous.  The  former  is 
nearly  always  bilateral,  is  an  acute  process,  and  is  generally 
unmistakably  secondary  to  tuberculosis  elsewhere  in  the 
body.  The  caseous  variety  runs  a  chronic  course ;  it  usually 
begins  as  a  unilateral  affection,  although  the  other  organ  is 
commonly  ultimately  involved,  and  a  primary  focus  may  or 
may  not  be  apparent  in  some  other  structure. 

Symptoms. — Pain  in  the  lumbar  region,  usually  dull,  but 
sometimes  sharp,  like  that  of  renal  colic  ;  tenderness  on  press- 
ure ;  slight,  irregular  fever,  and  more  or  less  cachexia.  The 
urine  is  usually  acid  in  reaction,  and  may  contain  pus,  blood, 
albumin,  tubercle  bacilli,  cheesy  particles,  and  debris.  Tube- 
casts  are  rarely  found.  In  many  cases  enlargement  of  the 
affected  organ  can  be  detected  by  bimanual  palpation. 

Diagnosis.  Calculous  Pyelitis. — In  this  condition  pain  is 
usually  more  severe,  and  more  apt  to  be  affected  by  movement. 
Hsematuria  is  more  profuse,  and  is  often  excited  by  exertion. 
Cachexia  is  not  so  marked,  and  there  are  no  tubercle  bacilli  in 
the  urine. 

Prognosis. — Always  grave.  Without  intervention  the 
duration  is  from  a  few  months  to  three  years. 

Treatment. — When  the  renal  disease  appears  to  be  pri- 
mary and  the  patient's  strength  will  permit,  nephrectomy 
should  be  recommended.  The  mortality  in  operative  cases 
has  been  about  28  per  cent.  In  other  cases  the  treatment 
must  of  necessity  be  palliative. 


DISEASES  OF  THE  BLOOD  AND  THE 
DUCTLESS  GLANDS. 


NORMAL  BLOOD. 

In  health  the  blood  amounts  to  about  one-thirteenth  of 
the  body-weight.  JSTormally  there  are  approximately  5,000,- 
000  red  blood-corpuscles  in  the  cubic  millimetre.  This 
number  is  temporarily  diminished  during  menstruation,  ges- 
tation, lactation,  and  fatigue,  and  after  the  ingestion  of  much 
fluid.  Fasting  and  profuse  sweating  increase  the  number  of 
red  cells  by  concentrating  the  blood.  In  the  first  few  days 
of  life  the  number  per  cubic  millimetre  may  be  7,000,000  to 
8,000,000.  In  high  altitudes  the  number  is  also  increased. 
There  are  from  5,000  to  10,000  white  cells  in  the  cubic  milli- 
metre, the  ratio  of  white  to  red  cells  being  about  1  to  500. 
The  number  of  blood  plates  is  from  200,000  to  300,000. 

EXAMINATION  OF  THE  BLOOD. 

A  CLINICAL  study  of  the  blood  has  for  its  object  the  deter- 
mination of  the  percentage  of  hsemoglobiu,  the  specific  grav- 
ity, the  alkalinity,  the  number,  form,  and  relative  proportion 
of  the  various  corpuscles,  and  the  detection  of  free  pigment, 
bacteria,  and  animal  parasites. 

Estimation  of  Haemoglobin. — The  percentage  of  haemo- 
globin may  be  determined  by  either  Fleischl's  or  Gowers' 
apparatus,  although  the  former  is  preferable. 

Gowers'  hcemoglohinometer  consists  of  (1)  a  small  sealed  tube 
containing  coloring  matter  representing  the  color  of  normal 
blood  diluted  with  100  parts  of  water;  (2)  an  empty  tube  of 
the  same  size,  graduated  up  to  120  per  cent. ;  (3)  a  small  bot- 
tle with  a  pipette  stopper,  for  distilled  water;  (4)  a  capillary 


120  DISEASES    OF    BLOOD    AND    DUCTLESS    GLAKDS. 

pipette  for  measuring  20  c.mm.  of  blood ;  and  (5)  a  small 
lancet.  To  obtain  a  specimen  of  blood  the  tip  of  the  finger  or 
the  lobe  of  the  ear,  after  being  thoroughly  cleansed,  is  deeply- 
pricked  with  the  lancet,  so  that  the  blood  flows  freely  without 
squeezing ;  20  c.mm.  of  blood  are  then  drawn  into  the  capillary 
pipette,  and  are  immediately  blown  into  the  graduated  tube, 
in  which  have  been  previously  placed  a  few  drops  of  distilled 
water  to  prevent  coagulation.  After  shaking  the  mixture  to 
secure  diffusion  of  the  blood,  more  distilled  water  is  cautiously 
added,  with  occasional  shaking,  until  the  tint  in  the  sealed 
tube  is  reached.  The  height  of  the  column  of  the  fluid  in  the 
graduated  tube  will  indicate  the  percentage  of  haemoglobin. 

FleischVs  instrument  consists  of  a  metal  stand  with  a  circu- 
lar aperture  in  the  centre,  under  which  is  placed  a  reflector 
made  of  plaster-of-Paris.  The  aperture  is  fitted  with  a  small 
cell  having  a  glass  bottom,  and  divided  into  two  equal  com- 
partments. A  graduated  wedge  of  colored  glass  is  employed 
as  a  standard,  the  100  on  the  scale  being  intended  to  repre- 
sent the  percentage  of  haemoglobin  in  normal  blood.  This 
wedge  of  glass  is  so  arranged  that  when  moved  under  the 
stand,  one  compartment  of  the  cell  will  receive  white  light 
from  the  reflector,  and  the  other,  red  light  from  the  tinted  glass. 
A  small  capillary  tube  is  held  over  a  drop  of  blood  until  filled, 
and  is  then  washed  in  one  of  the  compartments  of  the  cell,  in 
which  has  been  previously  placed  some  distilled  water.  Both 
compartments  are  then  equally  filled  with  water,  and  the 
wedge  of  glass  is  moved  by  means  of  a  thumb-screw  until 
the  tints  in  the  two  chambers  are  exactly  the  same,  when  the 
percentage  of  haemoglobin  may  be  read  off. 

In  the  examination  it  is  necessary  to  use  artificial  light. 
The  100  mark  on  the  scale,  which  is  intended  to  represent  the 
percentage  of  haemoglobin  in  normal  blood,  is  too  high  for  the 
average  person,  85  or  90  per  cent,  rarely  being  exceeded. 

The  Specific  Gravity  of  the  Blood. — The  specific 
gravity  of  the  blood  in  health  varies  from  1050  to  1070.  In 
grave  anaemia  it  is  often  considerably  diminished.  Hammer- 
schlag's  method  consists  in  expelling  a  drop  of  blood  into  a 
mixture  of  chloroform  and  benzol,  one  or  the  other  of  these 


EXAMINATION    OF    THE    BLOOD.  J  21 

substances  being  subsequently  added  until  the  drop  neither 
rises  nor  falls.  The  specific  gravity  of  the  mixture  may  then 
be  ascertained  in  the  usual  way.  Lloyd  Jones  employs  mix- 
tures of  glycerine  and  water  of  different  densities,  and  notes 
the  specific  gravity  of  the  mixture  in  which  the  blood-drop 
remains  stationary. 

Alkalinity  of  the  Blood. — The  alkalinity  of  the  blood 
may  be  determined  by  titrating  with  a  standard  solution  of 
acetic  acid  until  a  change  of  color  is  produced  when  a  drop  is 
placed  on  a  plaster-of- Paris  plate  impregnated  with  neutral 
litmus. 

Enumeration  of  Corpuscles. — The  best  instrument  for 
estimating  the  number  of  corpuscles  is  the  hcemocytometer  of 
Thoma-Zeiss.  This  consists  of  a  glass  slide,  in  the  centre  of 
which  is  a  cell  -^  mm.  in  depth.  The  floor  of  the  cell  is  divided 
into  squares,  the  sides  of  which  are  -^  mm.  Twenty-five  small 
squares  constitute  a  large  square,  which  is  indicated  by  heavy 
lines.  The  blood  is  mixed  in  a  melangeur — that  is,  a  capil- 
lary tube  one  extremity  of  which  is  blown  into  a  bulb  having 
a  capacity  of  100  c.mm.  The  melangeur  is  marked  at  0.5,  1 
c.mm.  and  101  c.mm.  A  drop  of  blood  issuing  from  a  prick 
of  the  finger  or  lobe  of  the  ear  is  drawn  cautiously  into  the 
tube  to  the  1  c.mm.  mark.  The  point  is  quickly  wiped  and 
immersed  in  the  diluting  fluid  (2|  per  cent,  solution  of  potas- 
sium bichromate)  which  is  drawn  up  to  the  101  c.mm.  mark. 
The  instrument  is  now  shaken  to  secure  diffusion  of  the  blood. 
The  diluting  fluid  remaining  in  the  stem  of  the  melangeur  is 
now  blown  out,  and  a  drop  of  the  mixture  placed  in  the 
blood-counting  cell.  The  drop  in  the  cell  should  be  free  from 
bubbles,  and  the  cover-glass  so  adjusted  that  Newton's  rings 
appear  at  the  margin  of  the  drop.  Before  counting,  a  few 
minutes  should  be  allowed  for  the  corpuscles  to  settle  to  the 
bottom  of  the  cell.  The  number  of  corpuscles  is  then 
counted  in  sixteen  large  squares  (400  small  squares),  the  aver- 
age number  in  each  small  square  being  determined  by  divid- 
ing the  whole  sum  by  400.  This  number  is  then  multiplied 
by  400,000,-100  for  the  dilution,  and  20  X  20  X  10  for  the 
cube  of  the  cell. 


122  DISEASES    OF    BLOOD    AND    DUCTLESS    GLANDS. 

After  using,  the  melangeur  should  be  carefully  washed  in 
water,  alcohol,  and  ether. 

The  Study  of  the  White  Blood-corpuscles.^In  nor- 
mal blood,  five  varieties  of  white  blood-corpuscles  may  be 
observed  : 

1.  Lyni'phoeytes,  or  small  mononuclear  forms,  about  the  size 
of  red  blood-corpuscles,  with  large  deeply  staining  nuclei,  and 
a  narrow  margin  of  uon-granular  protoplasm.  They  have 
their  origin  in  the  lymph-glands,  and  constitute  about  20  to  30 
per  cent,  of  all  the  leucocytes. 

2.  Large  mononuclear  cells,  three  or  four  times  the  size 
of  the  red  blood-corpuscles,  with  oval  nuclei,  surrounded  by 
non-granular  protoplasm. 

3.  Transitional  forms,  differing  from  the  large  mononuclear 
cells    only  in    having   nuclei   with    indentations.     The    large 

Fig.  7. 


w 


Blood  in  lieno-medullary  leukeemia,  showing  several  inononuclear  neutrophiles 
(myelocytes),  one  polymorphonuclear  neutrophlle,  and  an  eosinophile  ;  a  nucleated 
red  corpuscle  and  a"  lymphocyte  are  seen  in  the  lower  part  of  the  illustration, 
stained  with  Ehrlich's  triple  mixture.    (From  Stengel's  Text-Book  of  Pathology.) 

mononuclear  forms  constitute  from   6  to  8  per  cent,   of  the 
whole  number  of  leucocytes. 

4.  Polynuclear  Forms,  or  Leucocytes  loith  Polymorphous 
Nuclei. — These  are  somewhat  smaller  than  the  large  mononu- 
clear forms,  and  contain  deeply-staining  nuclei  which  are  very 


EXAMIxVATION    OF    THE    BLOOD.  123 

variable  in  shape.  The  protoplasm  coutains  abundant  neutro- 
philic granules  (neutrophiles) — that  is,  granules  which  have  an 
affinity  for  a  combination  of  acid  and  basic  stains.  The  poly- 
nuclear  forms,  or  neutrophiles,  are  apparently  derived  from  the 
spleen  and  bone-marrow,  and  constitute  from  70  to  80  per 
cent,  of  all  forms. 

5.  EosinophUes. — These  resemble  in  general  appearance  the 
polynuclear  forms,  but  the  granules  are  larger,  more  highly 
refractive,  and  have  a  special  affinity  for  acid  stains,  particu- 
larly eosin.  They  have  their  origin  in  the  bone-marrow,  and 
constitute  from  2  to  4  per  cent,  of  all  forms. 

In  addition  to  the  normal  elements  above  mentioned,  cer- 
tain other  forms  may  be  observed  in  the  blood  of  disease. 
Thus  in  leukaemia  large  mononuclear  forms  (myelocytes) 
are  often  met  with,  the  protoplasm  of  which  is  studded  with 
neutrophilic  granules.  In  the  same  disease,  the  blood  occa- 
sionally contains  cells  resembling  those  normally  found  in 
connective  tissue  {MastzeUen).  They  are  peculiar  in  having 
granules  which  have  an  affinity  only  for  basic  stains. 

With  the  aid  of  a  one-twelfth  inch  oil-immersion  lens,  large 
and  small  leucocytes  can  be  readily  distinguished  in  prepara- 
tions of  fresh  blood,  but  to  study  satisfactorily  the  various 
forms  it  is  necessary  to  dry  and  then  stain  the  specimen. 

The  Drying  and  Staining  of  Blood. — A  small  drop 
of  blood,  secured  by  pricking  the  finger,  is  spread  into  a  film 
by  being  pressed  between  two  perfectly  clean  cover-glasses, 
which  are  then  drawn  apart  and  exposed  to  the  air  until  dry. 
The  cover-glasses  should  be  handled  with  forceps,  since  the 
moisture  of  the  fingers  distorts  the  corpuscles.  The  prepara- 
tion is  first  "fixed"  by  heating  on  a  copper  bar  for  several 
hours  at  a  temperature  of  110°  to  120°  C.,  or  by  immersing 
for  from  fifteen  minutes  to  half  an  hour  in  a  mixture  of  equal 
parts  of  absolute  alcohol  and  ether.  A  convenient  method  of 
staining  is  the  one  suggested  by  Stengel.  The  fixed  prepara- 
tion is  immersed  for  a  couple  of  minutes  in  a  1  per  cent,  solu- 
tion of  eosin  in  60  per  cent,  alcohol,  to  wdiich  has  been  added 
an  equal  quantity  of  water  at  the  time  of  staining.  The 
cover-glass  is  then  washed  in  water  and  counter-stained  iu 


124  DISEASES    OF    BLOOD    AND    DUCTLESS    GLANDS. 

Delafield's  hsematoxylin  for  a  minute,  and  finally  washed, 
dried,  and  mounted.  The  eosiuophile  granules  are  dark  red, 
the  red  corpuscles  lighter  red,  and  the  nuclei  of  the  white 
blood-corpuscles  almost  black.  Thayer  recommends  the  fol- 
lowing solution : 

Solution : 

Saturated  aqueous  solution  of  acid  fuchsin    ....  2      parts. 

Water 3         " 

Saturated  aqueous  solution  of  orange-green    ....  6.25     " 
Saturated  aqueous  solution  of  methyl-green  ....  6  " 

To  which  is  added  drop  by  drop  while  the  solution  is  shaken : 

Water      15  parts. 

Alcohol 10      " 

Glycerin 5      " 

The  fixed  specimen  is  stained  in  this  solution  for  from  three 
to  four  minutes,  washed  in  water,  dried  in  the  air,  and  mounted 
in  balsam.  The  nuclei  of  white  blood-corpuscles  appear  green, 
the  eosinophile  granules  dark  red,  the  neutrophile  granules 
violet,  the  red  blood-corpuscles  orange,  and  the  nuclei  of  any 
existing  nucleated  red  blood-corpuscles  dark  green. 

PLETHORA. 

An  increase  in  the  whole  quantity  of  blood.  It  is  very 
doubtful  whether  such  a  condition  can  be  more  than  transi- 
tory. 

HYDREMIA. 

An  excess  of  water  in  the  blood.  As  a  loss  of  corpuscular 
elements  is  generally  replaced  by  the  addition  of  water  ex- 
tracted from  the  tissues,  most  anaemias  are  associated  with 
hydrsemia.  The  condition  is  more  marked  in  general  dropsy. 
Temporary  hydrsemia  is  produced  by  the  excessive  ingestion 
of  fluids. 

ANHYDR^MIA. 

A  deficiency  of  fluid  in  the  blood.  It  is  observed  in 
starvation,  immediately  after  hemorrhage,  and  after  copious 
discharges,  as  in  cholera. 


MELAN.EMIA — KUCi. BATED    EED    CELLS.  125 

MELAN^MIA. 

Melan^mia,  or  the  presence  of  free  pigment  in  the  blood, 
usually  results  from  chronic  malarial  infection.  It  is  occa- 
sionally associated  with  melanosarcoma  and  Addison's  dis- 
ease. 

POLYCYTHEMIA. 

Polycythsemia,  or  an  increase  in  the  number  of  red  cells,  is 
an  apparent  condition  in  blood  taken  from  cyanosed  parts. 
It  is  observed  temporarily  in  the  new-born,  in  recovery  from 
certain  ansemias,  after  transfusion  of  blood,  and  in  blood  con- 
centrated by  excessive  discharges.  Marked  polycythsemia  is 
sometimes  produced  by  residence  in  high  altitudes  and  by 
certain  poisons,  such  as  phosphorus  and  carbon  monoxide. 

MICROCYTOSIS  AND  MACROCYTOSIS. 

Microcytosis  and  macrocytosis  are  conditions  in  which  the 
red  cells  are  respectively  diminished  and  increased  in  size. 
They  may  occur  in  any  form  of  severe  anaemia,  but  they  are 
especially  marked  in  pernicious  ansemia. 

POIKILOCYTOSIS. 

Poikilocytosis,  a  condition  in  which  the  red  cells  are 
irregular  in  shape,  is  common  in  grave  anaemias,  especially 
pernicious  anaemia. 

NUCLEATED  RED  CELLS. 

Nucleated  red  cells  are  divided  into  three  forms — normo- 
blasts, macroblasts,  and  microblasts.  The  first  resemble  in 
size  and  color  a  normal  red  cell,  the  second  are  larger,  and  the 
third  smaller.  Nucleated  red  cells  are  not  found  normally 
in  the  circulating  l)lood  ;  they  are  present,  however,  in  grave 
forms  of  anaemia. 


126  DISEASES   OF   BLOOD   AND   DUCTLESS   GLANDS. 


LEUCOCYTOSIS. 

Leucocytosis,  or  hyperleucocytosis,  is  an  increase  in  the 
namber  of  white  blood-corpuscles.  It  occurs  physiologically 
in  the  new-born,  during  digestion,  in  pregnancy,  after  partu- 
rition, and  after  massage,  exercise,  or  cold  bathing.  In 
physiological  leucocytosis  the  relative  proportions  of  the  dif- 
ferent forms  of  white  cells  to  each  other  are  not  materially 
changed. 

Pathological  leucocytosis  is  observed  in  the  following  con- 
ditions : 

1.  Inflammation.  There  is  an  absolute  increase  in  the 
polynuclear  forms. 

2.  Infectious  diseases.  Most  infections  excite  leucocytosis, 
but  the  condition  is  often  wanting  in  typhoid  fever,  malaria, 
measles,  influenza,  and  tuberculosis.  In  any  infection  in 
which  the  toxsemia  is  intense,  or  the  resistance  of  the  indi- 
vidual is  slight,  leucocytosis  may  be  wanting. 

3.  Malignant  disease. 

4.  Hemorrhage, 

5.  Toxsemia.  Under  this  head  are  included  jaundice, 
ursemia,  ptomaine-poisoning,  and  gout.  Many  chemical 
substances — coal-gas,  phosphorus,  quinine,  etc. — also  pro- 
duce it. 

LEUCOP^NIA. 

Leucopsenia  is  a  diminution  in  the  number  of  white  cells. 
It  is  observed  in  certain  infections,  particularly  those  which 
do  not  produce  leucocytosis,  in  inanition,  and  in  pernicious 
ansemia. 

LIP^MIA. 

Lipsemia,  the  presence  in  the  blood  of  minute  fat-globules, 
may  be  noted  in  health.  Abnormal  quantities  of  fat  are  ob- 
served in  diabetes,  alcoholism,  and  in  conditions  associated 
with  deficient  oxidation,  such  as  phthisis  and  emphysema. 


BLOOD    PARASITES ANEMIA.  127 

BLOOD  PARASITES. 

The  following  parasites  have  been  detected  in  the  blood  : 
Filaria  sanguinis  hominis,  jDlasmodium  malarise,  spirochsete 
of  relapsing  fever ;  bacilli  of  anthrax,  glanders,  typhoid  fever, 
tuberculosis,  tetanus,  and  influenza  ;  diplococcus  pneumonise, 
streptococcus,  staphylococcus,  gonococcus,  and  bacillus  coli 
communis. 

OLIGOCHROM^MIA. 

Oligochromsemia,  or  deficiency  of  haemoglobin,  is  usually 
proportionate  to  the  reduction  in  the  number  of  red  cells,  but 
there  are  two  exceptions,  namely,  in  chlorosis,  in  which  dis- 
ease the  red  cells  may  be  reduced  only  20  or  30  per  cent., 
while  the  haemoglobin  may  be  reduced  50  or  60  per  cent., 
and  in  pernicious  anaemia,  in  which  disease  the  blood-count 
is  very  low,  while  the  corpuscles  are  relatively  rich  in  haemo- 
globin. 

The  color  index  represents  the  relation  between  the  number 
of  cells  and  the  quantity  of  haemoglobin.  In  a  patient  hav- 
ing 2,500,000  red  cells  per  cubic  millimetre  (50  per  cent.), 
and  40  per  cent,  of  haemoglobin  the  color  index  would  be 
40 

-        =:  0.8. 

50 

OLIGOCYTH.EMIA. 

Oligocythaemia,  a  diminution  in  the  number  of  red  cells, 
occurs  in  all  forms  of  anaemia,  but  it  is  especially  marked  in 
pernicious  anaemia  and  in  advanced  malignant  disease,  where 
the  number  may  fall  below  a  million  per  cubic  millimetre. 

ANEMIA. 

Anaemia  is  a  condition  in  which  the  blood  is  deficient  in 
quantity  or  in  one  or  more  of  its  constituents. 

Varieties. — (1)  Symptomatic  or  secondary  anaemia.  (2) 
Essential  or  primary  anaemia. 

Symptoms. — All  forms  of  anaemia  have  the  following 
symptoms  in  common  :  Pallor  of  skin  and  raucous  membranes, 
loss  of  strength,  and,  in  severe  cases,  febrile  paroxysms  and 
ecchymoses. 


128  DISEASES   OF    BLOOD    AND    DUCTLESS    GLANDS. 

Circulation. — A  full,  soft,  and  rapid  pulse,  unnatural  pul- 
sation of  the  cervical  vessels,  palpitation  of  the  heart,  hsemic 
murmurs,  and  slight  dropsy,  beginning  in  the  feet. 

Resj:) iration. — Hu rried  b reathing. 

Digestion.- — Dyspepsia. 

Nervous  System. — Headache,  vertigo,  disturbed  sleep,  neu- 
ralgic pains,  and  tendency  to  syncope. 

Symptomatic  Ansemia. 

Etiology. — Symptomatic  or  secondary  anaemia  usually 
results  from  one  of  three  causes  :  (1)  Insufficient  nutriment 
entering  the  circulation  (inadequate  food,  bad  air,  chronic 
gastritis,  cancer  of  the  pylorus,  etc.).  (2)  Excessive  demands 
upon  the  blood-making  organs  (overwork,  hemorrhage, 
chronic  diarrhoea,  etc.).  (3)  Action  of  toxic  agents  (lead, 
malaria,  syphilis,  uraemia,  etc.). 

Symptoms. — In  addition  to  the  ordinary  j)henomena  of 
anaemia  the  blood-count  reveals  a  decrease  in  the  number  of 
red  cells  and  a  proportionate  deficiency  in  the  percentage 
of  haemoglobin.  The  number  of  poly  nuclear  leucocytes  is 
often  increased.  In  severe  form,  microcytes,  macrocytes,  and 
poikilocytes  are  present,  and  rarely  nucleated  red  cells. 

Prognosis. — This  depends  on  the  cause. 

Treatment. — This  includes  the  removal  of  the  cause, 
when  possible  ;  the  adoption  of  hygienic  measures,  and  the 
use  of  iron,  arsenic,  and  general  tonics. 

PERNICIOUS  ANiEMIA. 

Definition. — A  grave  form  of  anaemia,  characterized  by  a 
great  deficiency  in  the  number  of  red  cells  and  unassociated 
with  any  definite  causal  lesion. 

Etiology. — Forms  of  anaemia  clinically  identical  w^ith 
pernicious  anfemia  may  be  dependent  upon  the  presence  of 
certain  intestinal  parasites  (bothriocephalus  and  anchylo- 
stoma),  may  follow  parturition,  or  may  result  from  advanced 
atrophy  of  the  stomach.  In  many  cases  no  adequate  cause  is 
apparent.     The  disease  usually  appears  about  middle  life,  and 


PERNICIOUS    ANvEMIA.  129 

is  more  frequent  in  males.  According  to  one  theory,  it  re- 
sults from  increased  haemolysis  excited  by  poisons  absorbed 
from  the  intestinal  canal ;  according  to  another,  it  is  due  to 
defective  hsemogenesis. 

Pathology. — The  skin  has  a  lemon-yellow  hue,  the  sub- 
cutaneous fat  is  often  well  preserved,  and  the  muscles  are 
unusually  red.  The  organs  are  the  seat  of  fatty  degenera- 
tion. The  gastric  tubules  are  sometimes  atrophied.  The 
liver  contains  an  excess  of  iron,  the  pigment  being  distributed 
especially  in  the  outer  and  middle  zones  of  the  lobules.  The 
bone-marrow  is  dark  red,  soft,  and  contains  a  large  number 
of  nucleated  red  cells,  especially  macroblasts.  In  many 
cases  there  is  found  advanced  sclerosis  in  the  posterior  col- 
umns of  the  spinal  cord. 

Symptoms. — Intense  ansemia,  with  its  usual  symptoms  ;  a 
lemon-yellow  tint  to  the  skin ;  progressive  weakness  without 
much  emaciation  ;  moderate,  irregular  fever  ;  marked  gastric 
disturbances ;  and  sometimes  dark-colored  urine  from  the 
presence  of  urobilin. 

The  Blood. — The  drop  is  pale  and  watery.  Coagulation  is 
slow.  There  is  a  great  reduction  in  the  number  of  red  cells, 
often  to  1,000,000  or  less  ;  the  hsemoglobin  is  also  reduced, 
but  not  proportionately ;  the  red  cells  are  irregular  in  size 
and  shape  (microcytes,  macrocytes,  and  poikilocytes),  and 
there  are  many  nucleated  red  cells  present,  especially  the 
large  forms  (macroblasts).  The  number  of  white  cells  is  not 
increased. 

Diagnosis. — Atrojjhy  of  the  gastric  tubules  may  be  recog- 
nized by  analysis  of  the  gastric  juice,  and  the  presence  of 
intestinal  parasites  by  examination  of  the  feces.  In  obscure 
Gcincer  the  anaemia  may  be  as  intense,  but  there  is  usually 
marked  leucocytosis. 

Prognosis. — Pernicious  anaemia  usually  ends  fatally  within 
one  or  two  years.  Recovery  is  rare,  but  periods  of  improve- 
ment are  of  frequent  occurrence. 

Treatment.— Apart  from  hygienic  measures,  arsenic  is 
the  only  reliable  remedy.  Two  minims  of  Fowler's  solution 
may  be  given  after  each  meal  and  gradually  increased,  so 
that  at  the  end  of  three  weeks  the   patient   is    taking   20 


130  DISEASES    OF    BLOOD    AND    DUCTLESS    GLANDS. 

minims  thrice  daily.  Qildenia  of  the  eyelids  and  gastric  dis- 
turbance are  indications  of  intolerance,  and  call  for  the  tem- 
porary suspension  of  the  drug.  Raw  red  bone-marrow  (one 
or  two  ounces  daily),  with  equal  parts  of  glycerin,  is  a  useful 
adjuvant.  Inhalations  of  oxygen  and  subcutaneous  injections 
of  normal  salt  solution  may  give  temporary  relief  in  grave 
cases. 

LEUKOCYTH^MIA. 

(Leukaemia.) 

Definition. — A  disease  characterized  by  great  excess  of 
the  white  corpuscles,  with  lesions  of  the  spleen,  lymphatic 
glands,  or  bone-marrow. 

Etiology. — The  causes  are  obscure.  Male  sex,  middle 
life,  heredity,  malaria,  bad  hygienic  conditions,  and  repeated 
hemorrhages  are  predisposing  factors.  It  is  probably  an 
infectious  disease. 

Varieties. — Spleno-medullary  and  lymphatic ;  the  first 
is  the  more  common. 

Pathology. — There  is  extreme  emaciation.  The  heart 
and  large  veins  are  filled  with  clots  of  a  greenish  color  and 
puriform  appearance.  The  spleen  is  much  enlarged  from  a 
true  hyperplasia.  It  is  of  a  brownish  color,  and  is  often 
studded  with  pale  gray  lymphoid  nodules.  The  liver  is  often 
enlarged  from  the  infiltration  of  leucocytes  between  the  liver 
cells  and  from  the  presence  of  distinct  lymphoid  growths. 
The  organs  generally  may  be  the  seat  of  leuksemic  nodules — 
i.e.,  masses  of  proliferating  leucocytes.  In  the  medulla  of 
the  long  bones  the  fat  is  replaced  by  material  resembling  pus 
(pyoid  marrow),  which  histologically  is  composed  of  numerous 
nucleated  red  cells  and  white  cells,  many  of  the  latter  being 
myelocytes.  The  lymphatic  variety  is  characterized  by 
marked  hyperplasia  of  all  the  lymphatic  glands.  In  the 
spleno-medullary  form  the  lymph-glands  are  often  more  or 
less  enlarged. 

Symptoms. — To  the  ordinary  manifestations  of  intense 
anaemia  are  added  the  following  symptoms  :  Moderate,  irregu- 
lar fever;  hemorrhages  from  mucous  membranes;  enlargement 
of  the  spleen,  liver,  and  lymphatic  glands ;  and  sometimes 


PSEUDO-LEUKEMIA.  131 

dimness  of  vision  from  retinal  hemorrhage  or  leuksemic  de- 
posits. 

The  Blood  of  Spleno-meduUary  Leukcemia. — Examination 
reveals  a  reduction  in  the  number  of  red  cells,  and  a  great 
excess  of  white  cells  (100,000  to  800,000),  many  of  the  latter 
being  myelocytes — i  e.,  large  niononuclear  forms  containing 
fine  neutrophilic  granules,  and  not  found  in  normal  blood. 

The  Blood  of  Lymphatic  Leukcemia. — Examination  reveals 
a  reduction  in  the  number  of  red  cells  and  an  excess  of  white 
cells,  about  90  per  cent,  of  the  latter  being  lymphocytes. 

Diagnosis.  Leueocytosis. — In  thi«  condition  the  excess 
of  leucocytes  is  chiefly  of  the  polynuclear  forms. 

Hodghhv's  disease  resembles  lymphatic  leukaemia,  but  in 
the  former  there  is  an  absence  of  leueocytosis. 

Prognosis  and  Treatment. — Recovery  rarely  follows. 
Death  usually  results  in  from  one  to  three  years  ;  acute  cases 
may  terminate  fatally  in  the  course  of  a  few  weeks.  The 
treatment  is  the  same  as  that  of  pernicious  anaemia. 

PSEUDO-LEUKEMIA. 

(Hodgkin's  Disease,    Lymphatic  Anasmia,   Malignant 
Lymphoma.) 

Definition. — A  disease  characterized  by  hyperplasia  of 
the  lymphatic  glands  and  progressive  anaemia,  without  a 
marked  excess  of  white  corpuscles. 

Etiology. — The  causes  are  unknown.  It  is  most  com- 
monly seen  in  young  adults  of  the  male  sex.  In  some 
instances  it  has  apparently  followed  an  ordinary  adenitis. 
An  infectious  origin  has  been  suggested. 

Pathology. — There  is  a  marked  hyperplasia  of  the  lym- 
phatic glands — cervical,  axillary,  mediastinal,  inguinal,  and 
retroperitoneal,  the  spleen  and  bone-marrow  often  sharing  in 
the  process. 

Symptoms. — The  disease  resembles  lymphatic  leukaemia, 
but  there  is  an  absence  of  leueocytosis.  The  glands  of  the 
neck  are  usually  first  affected  ;  the  swellings  are  painless, 
freely  movable,  and  only  very  rarely  suppurate. 


132  DISEASES   OF    BLOOD    AND    DUCTLESS    GLANDS. 

Diagnosis. — Tuberculous  adenitis  is  more  apt  to  affect  the 
submaxillary  glands  and  is  often  unilateral ;  moreover,  sup- 
puration of  the  glands  is  common  in  tuberculosis. 

Prognosis  and  Treatment. — Hodgkin's  disease  is  almost 
invariably  fatal.  The  duration  is  from  a  few  months  to 
three  years.  The  treatment  is  the  same  as  that  of  pernicious 
anaemia. 

CHLOROSIS. 

(Green  Sickness,  Primary  Anaemia.) 

Etiology. — The  predisposing  causes  are  age  (puberty), 
sex  (females,  rarely  males),  and  bad  hygiene  (poor  food,  im- 
pure air,  overwork,  and  lack  of  sunlight).  The  absorption 
of  ptomaines  from  the  bowel  has  been  suggested  as  the  excit- 
ing cause. 

Pathology. — In  some  fatal  cases  imperfect  development 
of  the  circulatory  system  and  of  the  genitalia  has  been  ob- 
served. 

Symptoms. — Anaemia  with  its  usual  manifestations ;  a  very 
marked  reduction  in  the  hsemoglobiu  without  a  corresponding 
reduction  in  the  number  of  red  blood-cells ;  a  greenish  tint  of 
the  skin  ;  a  capricious  appetite  (pica) ;  constipation ;  pallor  and 
weakness  without  loss  of  flesh  ;  and  a  tendency  to  hysterical 
outbreaks  and  to  menstrual  disorders. 

Complications. — Gastric  ulcer,  dilatation  of  the  stomach, 
gastralgia,  amenorrhoea,  phthisis,  exophthalmic  goitre,  and 
thrombosis. 

Prognosis. — Appropriate  treatment  is  followed  by  a  speedy 
recovery,  but  relapses  are  common. 

Treatment. — The  duration  of  the  disease  is  materially 
shortened  by  rest  and  the  regulation  of  the  diet.  The 
constipation  should  be  relieved  by  saline  laxatives.  The 
special  remedy  is  iron,  which  should  be  given  in  ascending 
doses. 

R    Ferri  sulphatis  ex., 

Potassii  carbonatis,  aa  gr.  xl. — M. 
Ft.  in  pil.  No.  xx. 
Sig. — Three  pills  daily,  increased  to  nine  pills  daily. 


Addison's  disease.  133 

ADDISON'S  DISEASE. 

DEFiNiTioisr. — A  constitutional  disease,  characterized  ana- 
tomically by  a  degeneration  of  the  suprarenal  capsules,  and 
clinically  by  pigmentation  of  the  skin,  ansemia,  and  prostration. 

Etiology. — Male  sex,  jniddle  life,  and  laborious  work 
are  predisposing  factors. 

Pathology. — In  most  instances  tuberculosis  of  the  supra- 
renal capsules  is  discovered.  Other  affections,  such  as  tumors 
and  degeneration  of  the  suprarenal  capsules,  may  produce  the 
disease.  In  a  few  instances  degenerative  changes  in  the 
abdominal  sympathetic  ganglia  have  been  the  only  discoverable 
lesions. 

Symptoms. — Moderate  anaemia,  with  bronzing  of  the  skin 
and  mucous  membranes,  great  weakness,  and  gastric  irritability 
are  its  chief  manifestations. 

Prognosis. — The  disease  has  been  considered  incurable, 
death  generally  resulting  in  from  one  to  two  years ;  but 
recently  good  results  have  followed  the  ingestion  of  supra- 
renal glands. 

Treatment. — The  general  treatment  includes  rest,  a  nutri- 
tious but  easily  assimilable  diet,  and  the  use  of  tonics  like  iron, 
arsenic,  quinine,  and  strychnine.  A  glycerine  extract  of  two 
fresh  suprarenal  capsules,  or  an  equivalent  amount  of  dried 
extract,  should  be  taken  daily. 

EXOPHTHALMIC  GOITRE. 

(Graves's  Disease,  Basedow^'s  Disease.) 

Definition. — A  nervous  affection,  characterized  by  pro- 
trusion of  the  eyeballs,  enlargement  of  the  thyroid  gland,  and 
palpitation. 

Etiology. — Early  adult  life,  female  sex,  and  nervous  tem- 
perament are  the  predisposing  causes.  It  sometimes  develops 
suddenly  under  emotional  excitement,  such  as  fright,  grief, 
and  anxiety. 

Pathology. — The  pathogenesis  of  Graves's  disease  is 
still  undetermined.  Some  attribute  the  phenomena  to  a 
lesion  of  the  medulla,  others  to  a  disturbance  of  the  sympa- 


13-i  DISEASES    OF    BLOOD    AXD    DUCTLESS    GLA^'DS. 

thetic  nervous  system,  Avhile  moclerii  research  indicates  that 
the  chief  factor  is  overaction  of  the  thyroid  gland  (hyperthy- 
roidation).  Greenfield  found  the  tubular  spaces  of  the  gland 
proliferated  and  the  colloid  matrix  replaced  by  a  more  mucoid 
material. 

Symptoms.  Cardiac  Phenomena.  —  Acceleration  of  the 
pulse  (100-150)  and  palpitation,  both  greatly  exaggerated  by 
excitement ;  hypertrophy  of  the  heart  from  its  rapid  action  ; 
occasionally  a  soft  systolic  murmur  at  the  apex. 

Ocular  Phenomena. — Bilateral  protrusion  of  the  eyeballs; 
Graefe's  sign,  which  consists  in  a  failure  of  the  upper  lid  to 
follow  the  eyeball  when  the  latter  is  directed  downwards ; 
widening  of  the  palpebral  angle  (Stellwag's  sign).  Vision  is 
usually  unimpaired. 

Thyroid  Phenomena. — Enlargement  of  the  thyroid  is  often 
the  last  symptom  to  appear ;  one  or  both  lobes  of  the  gland 
may  be  affected.  Inspection  reveals  enlargement  with  pulsa- 
tion ;  palpation  detects  a  soft  swelling  and  a  purring  thrill ; 
auscultation  may  yield  a  hniit. 

Nervous  Phenomena. — The  following  are  sometimes  ob- 
served :  A  tremor  of  the  hands  or  of  the  entire  body ;  hypo- 
chondriasis ;  acute  mania ;  or  vitiligo  and  chloasma. 

General  Phenomena.  —  Anaemia,  failure  of  health  and 
strength,  and  slight  febrile  paroxysms. 

Diagnosis. — It  should  be  borne  in  mind  that  one  of  the 
three  important  symptoms  may  be  absent  throughout  the 
disease.  In  some  cases  palpitation  and  throbbing  of  the 
cervical  vessels  may  be  the  only  phenomena. 

Goitre  may  be  distinguished  from  exophthalmic  goitre  by  the 
absence  of  cardiac,  ocular,  and  nervous  symptoms. 

Prognosis. — The  disease  generally  runs  a  protracted  course. 
Some  cases  recover  entirely ;  many  improve  and  subsequently 
relapse ;  a  few  die,  after  a  short  illness,  from  heart  failure  or 
acute  mania. 

Treatment. — The  general  nutrition  must  be  improved  by 
rest,  a  liberal  diet,  and  the  use  of  such  tonics  as  iron,  quinine, 
and  arsenic.  The  application  of  mild  galvanic  currents  to  the 
neck  is  often  very  useful.  When  the  palpitation  is  marked, 
prompt  relief  often  follows  absolute  rest  and  the  application 


MYXCEDEMA.  135 

of  an  ice-bag  to  the  prsecordia.  The  most  reliable  internal 
remedies  are  strophanthiis,  digitalis,  belladonna,  and  ergot. 
Bromide  of  potassium  is  sometimes  useful  in  controlling  the 
nervous  symptoms.     Thyroid  extract  is  harmful. 

Operative  treatment  is  hazardous,  though  not  infrequently 
followed  by  excellent  results. 

MYXCEDEMA. 

Definition. — A  constitutional  affection,  characterized  by 
mucoid  degeneration  of  the  subcutaneous  tissues,  atrophy  of 
the  thyroid  gland,  and  mental  impairment. 

Etiology. — The  disease  is  much  more  frequent  in  women 
than  in  men.  It  is  occasionally  hereditary.  It  usually  devel- 
ops in  middle  life.  The  immediate  cause  is  atrophy  of  the 
thyroid  gland. 

A  congenital  form  of  myxoedema  is  observed  in  cretinism, 
and  an  analogous  condition  (operative  myxcedema  or  cachexia 
strumipriva)  frequently  follows  total  extirpation  of  the  thyroid 
gland. 

Symptoms. — It  is  manifested  by  a  gradual  swelling,  partic- 
ularly marked  in  the  face,  supraclavicular  regions,  and  hands. 
Unlike  oedema,  the  parts  do  not  pit  on  pressure,  but  are  firm 
and  elastic.  The  skin  is  dry  and  harsh.  The  hair  is  dry  and 
brittle.  The  thyroid  gland  is  atrophied.  A  pecular  slowness 
in  thought,  speech,  and  movements  is  a  characteristic  symp- 
tom. The  temperature  of  the  body  is  subnormal.  There  is 
impairment  of  the  special  senses.  Sensory  phenomena  are 
common,  such  as  coldness,  numbness,  and  tingling.  The  urine 
is  often  increased  in  quantity,  and  occasionally  contains  albu- 
min, sugar,  and  tube-casts. 

Complications. — Insanity,  tuberculosis,  exophthalmic  goi- 
tre, and  nephritis. 

Diagnosis. — The  mental  dulness,  the  extreme  dryness  of 
the  skin,  the  absence  of  pitting  on  pressure  will  separate  myx- 
oedema from  Bright's  disease  with  oedema. 

Prognosis. — The  disease  was  formerly  considered  incurable, 
but  it  is  now  known  that  marked  amelioration  or  even  a  cure 
can  be  effected  by  appropriate  treatment. 


136  DISEASES    OF    BI.OOD    AND    DUCTLESS    GLANDS. 

Treatment. — Murray  was  the  first  to  demonsti^ate  the  value 
of  thyroid  juice  in  myxoedema.  A  glycerine  extract  or  a  dried 
extract  of  the  gland  may  be  employed ;  the  latter  is  very  effi- 
cient in  doses  of  one  grain,  gradually  increased  to  five  grains, 
three  times  a  day.  Residence  in  a  warm  climate  is  desirable. 
Warm  baths  followed  by  friction  and  massage  are  useful. 


DISEASES 


CIRCULATORY  SYSTEM. 


INSPECTION. 

Inspection  detects  the  apex-beat,  and  determines  its  position, 
force,  and  extent ;  any  abnormal  centres  of  pulsation  ;  and  any 
unnatural  prominence  over  the  prsecordial  region. 

The  Apex-beat. 

The  normal  position  of  the  apex-beat  is  in  the  fifth  inter- 
costal space,  about  an  inch  within  the  mammary  line  (a  line 
drawn  from  the  middle  of  the  clavicle  parallel  with  the 
sternum).  The  beat  is  usually  detected  by  inspection  or  pal- 
pation, but  when  these  methods  fail  it  may  be  localized  by 
auscultation,  the  point  in  the  region  of  the  apex  where  the 
first  sound  is  heard  with  maximum  intensity  corresponding 
to  the  beat. 

The  Effect  of  Respiration  and  Position  on  the  Apex-beat. — 
The  location  and  force  of  the  apex-beat  are  modified  by  the 
posture  of  the  patient  and  the  stage  of  the  respiratory  act.  In 
the  recumbent  position  the  apex-beat  may  be  elevated  an  inch 
or  more,  and  when  the  body  is  inclined  to  the  left,  the  heart 
being  a  more  or  less  movable  organ,  the  beat  may  be  detected 
in  the  mammary  line,  or  even  some  distance  to  its  outer  side. 

During  forced  inspiration  the  beat  may  become  imper- 
ceptible, or  if  such  is  not  the  case  it  may  be  found  some 
distance  below  its   usual    place,  on  account  of  the   upward 

(137) 


138  DISEASED   Of'   THE   (JIRCULATORY   SYSTEM. 

movement  of  the  ribs  in  the  inspiratory  act.  During  forced 
expiration,  the  air  being  driven  from  the  lung-tissue  in  front 
of  the  heart,  the  beat  becomes  more  forcible,  and  its  position 
elevated  on  account  of  the  descent  of  the  ribs  which  occurs  in 
expiration. 

In  view  of  the  influence  exerted  by  respiration  and  position 
on  the  apex-beat  the  patient,  as  a  rule,  should  be  examined  in 
the  erect  or  sitting  posture,  while  breathing  quietly. 

Displacement  of  the  Apex-beat. 

Displacement  to  the  left  may  result  from  : — 

1.  Hypertrophy  and  dilatation  of  the  heart  (down  and  to 
the  left.) 

2.  Pericardial  effusion  (up  and  to  the  left). 

3.  Chronic  diseases  of  the  left  luug  and  pleura,  associated 
with  retraction — as  fibroid  phthisis  and  pleural  adhesions.. 

4.  Abdominal  tumors  and  effusions  (up  and  to  the  left). 

5.  The  pressure  of  a  pleural  effusion  on  the  right  side  (up 
and  to  the  left). 

Displacement  to  the  right  may  be  caused  by  : — 

1.  Chronic  disease  of  the  right  lung  or  pleura  associated  with 
retraction. 

2.  Pressure  of  a  pleural  effusion  on  the  left  side. 
Displacement  dowmoard  may  result  from  : — 

1.  Hypertrophy  and  dilatation  of  the  heart,  chiefly  the  lefl 
ventricle. 

2.  Pressure  of  solid  growths  in  the  upper  mediastinum. 

3.  Aneurism  of  the  aortic  arch. 

4.  Enlargement  of  the  liver,  causing  traction  through  the 
central  tendon  of  the  diaphragm.     (Paul.) 

Deformity  of  the  chest  may  cause  displacement  in  any 
dii-ection. 


Changes  in  Force  and  Extent  of  tlie  Apex-heat. 

The  force  and.  extent  may  be  increased  by  : — 
1.  Hypertrophy  of  the  heart. 


INSPECTION.  139 

2.  Excited  action  of  the  heart,  from  drugs,  reflex  irritation, 
excitement,  or  diseases,  as  exophthalmic  goitre. 

3.  Shrinking  of  the  lungs,  as  in  phthisis. 
A  weak  apex-beat  may  be  noted  in  : — 

1.  Healthy  people. 

2.  Degeneration  or  dilatation  of  the  heart. 

3.  Pericardial  effusion. 

4.  Emphysema. 

5.  Shock  or  collapse. 

Abnormal  Centres  of  Pulsation. 

Epigastric  pulsation  may  result  from  : — 

1.  Excited  action  of  the  heart  from  any  cause. 

2.  Enlargement  of  the  right  ventricle. 

3.  A  pulsating  aorta  noted  in  certain  nervous  and  anaemic 
patients. 

4.  Aortic  aneurism. 

5.  Tumors  of  the  left  lobe  of  the  liver  resting  on  the  aorta. 
Pulsation  at  the  base  of  the  heart  may  result  from  : — 

1.  Aneurism  of  the  aortic  arch. 

2.  Cardiac  hypertrophy. 

3.  Shrinking  of  the  lungs,  as  in  phthisis. 

Pulsation  in  the  left  axillary  I'egion  may  result  from  : — 

1.  Enlargement  of  the  heart. 

2.  A  tense  purulent  effusion  in  the  left  pleural  sac  (pulsat- 
ing empyema). 

3.  Aneurism. 

4.  Chronic  diseases  of  the  left  lung  and  pleura,  associated 
with  retraction. 

Unnatui^al  pulsation  in  the  carotids  may  result  from  : — 

1.  Excitement  of  the  heart  from  any  cause. 

2.  Exophthalmic  goitre. 

3.  Anaemia. 

4.  Valvular  disease,  especially  aortic  regurgitation. 

5.  Aneurism  or  dilatation  of  the  vessels. 

6.  Unnatural  elasticity  of  the  vessels,  noted  in  certain  ner- 
vous and  anaemic  patients. 


140  DISEASES   OF   THE   CIRCULATORY   SYSTEM. 

Jugular  Pulsation. 

The  jugular  vein  often  becomes  distended  in  forced  expira- 
tion and  coughing.  Distention  of  the  jugular  vein  is  some- 
times noted  in  adherent  pericardium. 

A  true,  rhythmical  venous  pulsation  usually  results  from 
tricuspid  regurgitation. 

A  pulsation  may  be  transmitted  to  the  jugular  vein  from  the 
underlying  carotid,  but  this  false  pulsation  will  still  continue 
when  light  pressure  is  made  on  the  vein  at  the  root  of  the 
neck,  while  the  true  venous  pulse  will  cease. 

Prsecordlal  Prominence. 

Unnatural  prominence  of  the  'prcecordia  may  result  from  : — 

1.  Hypertrophy  of  the  heart. 

2.  Dilatation  of  the  heart. 

3.  Pericardial  effusion. 

PAI.PATI01V. 

This  not  only  determines  the  position,  force,  extent,  and 
rhythm  of  the  apex-beat,  but  also  detects  the  existence  of  any 
fremitus  or  thrill. 

A  thrill  is  a  vibratory  sensation  likened  to  that  received 
when  the  hand  is  placed  on  the  back  of  a  purring  cat.  Thrills 
at  the  base  of  the  heart  may  result  from  valvular  lesions,  athe- 
roma of  the  aorta,  aneurism,  and  from  roughened  pericardial 
surfaces,  as  in  pericarditis. 

A  presystolic  thrill  at  the  apex  is  almost  pathognomonic  of 
mitral  stenosis. 

percussio:n^. 

This  determines  the  shape  and  extent  of  the  cardiac  dulness. 

The  normal  area  of  superficial  or  absolute  percussion-dulness 
(the  part  uncovered  by  lung)  is  detected  by  light  percussion, 
and  extends  from  the  fourth  left  costo-sternal  junction  to  the 


AUSCULTATION.  141 

apex-beat;  from  the  apex-beat  to  the  junction  of  the  xiphoid 
cartilage  with  the  sternum  and  thence  up  the  left  border  of 
the  sternum. 

The  normal  area  of  deep  percussion-dulness  (the  heart  pro- 
jected on  the  chest-wall)  is  detected  by  firm  percussion,  and 
extends  from  the  third  left  costo-sternal  articulation  to  the 
apex-beat;  from  the  apex-beat  to  the  junction  of  the  xiphoid 
cartilage  with  the  sternum;  and  thence  up  the  right  border  of 
the  sternum  to  the  third  rib.  The  lower  level  of  the  cardiac  dul- 
ness  fuses  with  the  liver  dulness,  and  can  rarely  be  determ- 
ined by  percussion. 

The  area  of  cardiae  dulness  is  increased  in  :  (1)  Hypertrophy 
and  dilatation  of  the  heart.  (2)  Pericardial  effusion.  It  is 
apparently  increased  in  shrinking  of  the  lungs,  as  in  phthisis. 

The  area  of  cardiac  dulness  is  diminished  in  :  (1)  Emphy- 
sema. (2)  Pneumothorax.  (3)  Pneumopericardium  (rare). 
(4)  Gaseous  distention  of  the  stomach. 

AUSCULTATIOK^. 

This  determines  the  quality,  intensity,  and  rhythm  of  the 
heart-sounds,  and  detects  the  presence  of  any  adventitious 
sounds,  as  murmurs.  The  two  sounds  heard  over  the  heart  have 
been  represented  by  the  syllables,  "  lubb,  tup."  The  first  sound 
(systolic)  results  from  contraction  of  the  ventricle,  tension  of 
the  auriculo-ventricular  valves,  and  the  impact  of  the  heart 
against  the  chest-wall,  and  is  synchronous  with  the  apex-beat 
and  carotid  pulse.  This  sound  is  prolonged  and  dull.  After 
the  first  sound  there  is  a  short  pause,  and  then  follows  the 
second  sound  (diastolic),  which  results  from  the  closure  of  the 
aortic  and  pulmonary  valves.  This  sound  is  short  and  high- 
pitched.  After  the  second  sound  a  longer  pause  follows  be- 
fore the  first  is  again  heard. 

The  Intensity  of  the  Heart- sounds. 

Both  sounds  are  accentuated  in  :  (1)  Excitement  of  the  heart 
from  any  cause.  (2)  Anaemia.  (3)  Cardiac  hypertrophy. 
(4)  Subjects  with  thin  chest-walls.  (5)  Consolidation  of  the 
lung,  as  in  phthisis  and  pneumonia. 


142  DISEASES   OF   THE   CIECULATORY   SYSTEM. 

Accentuation  of  the  aortic  second  sound  results  from  :  (1)  Hy- 
pertrophy of  the  left  veutricle.  (2)  High  arterial  tension,  as 
in  arterio-sclerosis  and  Bright's  disease,     (3)  Aortic  aneurism. 

Accentuation  of  the  pulmonary  second  sound  results  from  : 

(1)  Pulmonary  obstruction,  as  in  emphysema,  pneumonia,  and 
the  congestion  of  the  lungs  following  mitral  disease.  (2)  Hy- 
pertrophy of  the  right  ventricle. 

Weakness  of  both  sounds  is  noted  in  :    (1)  General  obesity. 

(2)  General  debility.  (3)  Degeneration  or  dilatation  of  the 
heart.     (4)  Pericardial  or  pleural  effusion.     (5)  Emphysema. 

Reduplication  of  tlie  Heart-sounds. 

This  is  probably  due  to  a  lack  of  synchronous  action  in  the 
valves  of  the  two  sides  of  the  heart,  and  results  from  many  con- 
ditions, but  notably  from  increased  resistance  in  the  systemic 
or  the  pulmonary  circulation,  as  in  arterio-sclerosis  of  chronic 
nephritis  and  in  emphysema.  It  is  frequently  noted  iu  mitral 
stenosis  and  pericarditis. 

Adventitious  Sounds  or  Murmurs. 

A  murmur  is  an  abnormal  sound  heard  over  the  heart  or 
bloodvessels,  and  may  result  from  :  (1)  Obstruction  or  regur- 
gitation at  the  valves  following  endocarditis.  (2)  Dilatation 
of  the  ventricle  or  relaxation  of  its  walls,  rendering  the  valves 
relatively  insufficient.  (3)  Aneurism.  (4)  A  change  in  the 
blood  constituents,  as  in  ansemia.  (5)  Koughening  of  the 
pericardial  surfaces,  as  in  pericarditis.  (6)  Irregular  action 
of  the  heart. 

Murmurs  produced  within  the  heart  are  termed  endocardial; 
those  produced  outside,  exocardial ;  those  produced  in  aneu- 
risms, bruits;  and  those  produced  by  anaemia,  hsemic  murmurs. 

Hsemic  Murmurs. 

Hsemic  murmurs  have  the  following  characteristics  :  They 
are  soft  and  blowing  in  character,  usually  systolic  in  time, 
heard  best  over  the  pulmonary  valves,  transmitted  into  the 


THE    PULSE.  143 

carotids,  accompanied  with  a  hum  in  the  veins  of  the  neck, 
associated  with  the  symptoms  of  anaemia,  and  do  not  cause 
cardiac  hypertro])hy. 

Pericardial  Friction-sounds. 

Pericardial  murmurs,  or  friction-sounds,  are  superficial, 
rough  and  creaking  in  quality,  to  and  fro  in  time,  not  trans- 
mitted beyond  the  preecordia,  and  may  be  modified  by  pressure 
of  the  stethoscope. 

The  Aneurisnial  Murniiu*,  or  Bruit. 

This  is  usually  loud  and  booming  in  character,  systolic  in 
time,  heard  best  over  the  aorta  or  base  of  the  heart,  and  is 
often  associated  with  an  abnormal  area  of  dulness  and  pulsa- 
tion, and  with  symptoms  resulting  from  pressure,  on  neighbor- 
ing structures. 

THE  PULSE. 

The  average  frequency  of  the  pulse  in  the  adult  is  between 
70  and  80  per  minute  At  birth  it  is  between  130  and  150; 
in  the  second  year  about  100,  and  so  it  gradually  lessens  as 
the  child  matures. 

Increased  frequency  of  the  Pulse  (Tachycardia). 

Habitual  frequency  is  sometimes  noted  in  health.  The 
frequency  may  be  temporarily  increased  by  erect  posture,  ex- 
citement, eating,  and  the  use  of  stimulants. 

Abnormal  frequencij  may  result  from — (1)  Pyrexia.  The 
pulse  usually  bears  a  definite  relation  to  the  temperature,  but 
in  certaiu  diseases,  as  scarlet  fever  and  septicaemia,  it  is  dispro- 
portionately rapid.  (2)  Exophthalmic  goitre.  (3)  Organic 
heart-disease.  (4)  Pressure  at  the  base  of  the  brain  sufficient  to 
paralyze  the  })neumogastrics,  as  in  clot,  tumor,  and  advani-ed 
meningitis.  (5)  Shock.  (6)  Reflex  irritation,  as  in  dyspepsia, 
ovarian,  or  uterine  disease.  (7)  An  independent  paroxysmal 
neurosis  ("  Essential  Paroxysmal  Tachycardia").  (8)  Certain 
drugs — belladonna,  nitrites,  alcohol,  etc.  (9)  Rheumatoid  ar- 
thritis (Sansom). 


144 


DISEASES   OF   THE    CIRCULATORY  SYSTEM. 


Infrequency  of  the  Pulse  [Bradycardia). 

Physiological  slowness  is  noted  in  repose,  fasting,  the  piier- 
perium,  old  age,  and  habitually  in  certain  people  (40  to  60  per 
minute). 

Pathological  infrequency  is  observed  in  many  conditions, 
notably — [1)  In  organic  heart  disease,  especially  fatty  degen- 
eration and  fibroid  induration.  (2)  In  jaundice.  (3)  From 
pressure  at  the  base  of  brain  sufficient  to  irritate  the  vagus, 
as  in  beginning  meningitis.  (4)  At  the  close  of  febrile  dis- 
eases, as  typhoid  fever,  pneumonia,  etc.  (6)  After  the  use  of 
certain  drugs,  as  digitalis,  aconite,  opium,  etc. 

Irregular  Rhytlim. 

(Arhythmia.) 

The  Intermittent  Pulse. — This  per  se  is  not  significant  of 
any  pathological  condition.  It  is  habitually  noted  in  certain 
people,  after  exercise,  eating,  excitement,  or  the  use  of  tobacco, 
tea,  or  coffee.  It  is  frequently  reflex  from  gastric,  hepatic, 
uterine,  or  renal  disease.  It  is  common  in  lithsemia  and  fatty 
degeneration  of  the  heart. 

There  may  be  a  false  intermission  or  infrequency  in  the 
radial  pulse  when  the  heart  fails  to  transmit  all  its  beats  to 
the  wrist.     This  condition  is  usually  indicative  of  a  weak  heart. 

The  Irregular  Pulse. — This  has  the  same  significance  as  the 
intermittent  pulse.  It  is  also  very  common  in  myocarditis 
and  valvular  disease,  especially  mitral  regurgitation. 

Fig.  8. 


Sphygmogram  of  the  trigeminal  pulse. 


The  Bigeminal  and  Trigeminal  Pulses. — Two  or  three 
regular  beats  followed  by  a  longer  pause.  They  have  the 
same  significance  as  the  irregular  pulse. 


THE    PULSE.  145 

The  Pulsus  Paradoxus. — One  which  is  more  or  less  sup- 
pressed at  the  close  of  each  full  inspiration.  It  is  thought  to 
be  due  to  the  compression  of  the  great  vessels  by  inflammatory 
adhesions,  the  latter  being  stretched  during  the  act  of  inspira- 
tion.    It  is  frequently  noted  in  adherent  pericardium. 

The  Dicrotic  Pulse. — A  pulse  in  which  the  main  beat  is 
quickly  followed  by  a  secondary  wave  or  slight  rebound  of 
the  vessel.     The  secondary  or  dicrotic  wave  results  from  a 

Fig.  9. 


Sphygmogram  of  a  dicrotic  pulse. 

recoil  of  the  relaxed  vessels  after  the  latter  have  been  dis- 
tended by  a  sharp  ventricular  contraction.  It  is  indicativ^e  of 
low  arterial  tension,  and  is  noted  especially  in  febrile  diseases 
and  low  states  of  the  nervous  system. 

Other  Variations  in  the  Pulse. 

The  High-tension  Pulse. — One  in  which  the  force  of  the 
beat  is  relatively  increased.  The  tension  may  be  roughly 
estimated  by  noting  the  amount  of  pressure  of  the  fingers  that 
is  required  to  arrest  the  beat. 

A  high-tension  pufee  is  observed  in  many  conditions,  notably 
in  cardiac  hypertrophy,  excitement  of  the  heart,  chronic  ne- 
phritis ;  in  cerebral  affections  irritating  the  vaso-motor  centre, 
such  as  apoplexy,  tumors,  and  beginning  meningitis ;  after 
the  use  of  certain  drugs,  as  digitalis,  ergot,  and  alcoholic 
stimulants;  in  chills;  in  pregnancy;  in  certain  neuroses,  as 
angina  pectoris,  epileptic  and  hysterical  seizures  ;  and  from 
contraction  of  the  capillaries  by  irritants  generated  in  the  body, 
as  in  lithgemia^  gout,  ureemia. 
10 


146  DISEASES   OF   THE   CIRCULATORY  SYSTEM. 

The  Low-tension  Pulse. — This  is  also  observed  in  many 
conditions,  notably  in  degeneration  of  the  heart,  in  collapse, 
in  debility,  in  fevers,  and  in  low  states  of  the  nervous  system. 

Venous  Pulse. — A  true  jugular  pulsation  is  often  noted  in 
tricuspid  regurgitation.  A  venous  pulse  in  the  dorsum  of  the 
hand  may  be  due  to  (1)  forcible  propulsion  of  blood  through 
the  capillaries,  as  in  aoi^tic  regurgitation  with  great  hyper- 
trophy of  the  left  ventricle;  or  (2)  to  extreme  relaxation  of 
the  arterioles  and  capillaries,  permitting  the  transmission  of 
the  pulse-wave,  as  in  grave  cachexia  and  anaemia. 

Asymmetrical  Radial  Pulses. — May  result  from :  (1) 
Anomalies  in  the  distribution,  size,  and  division  of  one  of 
the  vessels.  (2)  Aortic  aneurism.  (3)  An  embolus  or  an 
atheromatous  plate  within  the  vessel.  (4)  Fractures,  luxations, 
or  inflammatory  exudations  causing  compression  of  the  vessel. 
(5)  Compression  of  one  vessel  by  tumors  within  or  without 
the  thorax. 

"  Water-hammer  Pulse "  {Corrigan's  Ptdse). — Characterized 
by  a  short,  powerful  beat,  which  suddenly  collapses.  The 
peculiar  pulsation  may  be  distinctly  visible,  not  only  in  the 
carotids  but  throughout  the  brachial  artery.  This  pulse  is 
diagnostic  of  aortic  regurgitation  during  the  period  of  compen- 
sation, and  its  force  is  due  to  the  excessive  ventricular  hyper- 
trophy and  to  the  large  amount  of  blood  expelled  with  each 
systole ;  its  sudden  recession  is  due  to  the  incompetent  valves 
failing  to  support  the  column  of  blood. 

PAI.PITATIOIV. 

Definition. — A  rapid  and  tumultuous  action  of  the  heart 
perceptible  to  the  ]>atient.  Rapidity  not  perceptible  to  the 
patient  is  not  termed  palpitation. 

Etiology. — It  may  result  from  :  (1)  Reflex  irritation,  as 
from  gas  or  acid  in  the  stomach.  (2)  Excitement,  mental 
or  physical.  (3)  Organic  heart  disease.  (4)  Exophthalmic 
goitre.  (5)  Over-work,  as  in  the  ^'  irritable  heart"  of  un- 
trained recruits.  (6)  Anaemia.  (7)  Hysteria.  (8)  An  inde- 
pendent neurosis  (Essential  Paroxysmal  Tachycardia). 


DROPSY — GENERAL   CYANOSIS.  147 

DROPSY. 

Definition. — An  unnatural  collection  of  serous  fluid  in 
the  tissues  or  cavities  of  the  body. 

Etiology. — Dropsy  may  result  from  :  (1)  Certain  chronic 
visceral  aflFections  which  bring  about  venous  stasis,  as  diseases 
of  the  heart,  liver,  and  lung.  (2)  Local  obstruction  to  the 
venous  circulation  by  emboli,  thrombi,  tumors,  etc.  (3) 
Changes  in  the  composition  of  the  blood,  as  in  ansemia.  (4) 
Changes  in  the  walls  of  the  capillaries,  as  in  Bright's  disease. 
The  changes  are  probably  produced  by  poisons  circulating  in 
the  blood.  (5)  Disturbed  innervation,  as  in  hysteria  and 
angio-neurotic  oedema.  In  these  cases  the  drojjsy  is  due  to 
either  trophic  or  vaso-motor  influences. 

GEJVERAL  CYANOSIS. 

Definition. — Blueness  of  the  surface  from  insufiicient  oxi- 
dation of  the  blood. 

Etiology. — Cyanosis  results  from  :  (1)  Conditions  Avhich 
obstruct  the  entrance  of  air,  as  croup ;  oedema  of  the  larynx ; 
tumors  or  foreign  bodies  in  the  air-passages;  tumors  pressing  on 
the  air-passages;  emphysema;  pneumonia;  pleurisy;  paralysis 
of  the  respiratory  muscles,  as  in  bidbar  palsy  ;  and  spasm  of 
the  respiratory  muscles,  as  in  epilepsy,  tetanus,  etc.  (2)  An 
•^inability  to  get  blood  to  the  air,  as  in  all  forms  of  chronic 
heart  disease  ending  in  pulmonary  congestion. 

Congenital  Cyanosis  is  usually  associated  with  stenosis  of 
the  pulmonary  orifice,  an  imperfect  ventricular  septum,  or  a 
patulous  foramen  ovale;  it  probably  results  not  so  much 
from  direct  mixture  of  venous  and  arterial  blood,  as  from  the 
failure  of  the  blood  to  reach  the  lung,  or  from  general  venous 
congestion. 


148  DISEASES   OF   THE    CIRCULATORY   SYSTEM. 


PERICARDITIS. 

Definition.  —  An  iuflammatiou  of  the  pericardium,  or 
serous  covering  of  the  heart. 

Etiology. — (1)  Idiopathic,  from  exposure.  (2)  Traumatic. 
(3)  Secondary  to  neighboring  inflammations,  as  pleurisy, 
phthisis,  pneumonia,  mediastinal  disease.  (4)  Secondary  to 
some  general  disease,  as  rheumatism,  Bright's  disease,  septi- 
caemia, tuberculosis,  and  the  eruptive  fevers. 

Pathology. — In  the  early  stage  the  membrane  is  red, 
sticky  and  lustreless;  and  if  the  process  now  ceases,  the  con- 
dition is  termed  dry  jjericarditis. 

If,  however,  the  inflammation  continues,  an  exudate  is 
formed  which  may  be :  (1)  Sero-fibrinous,  (2)  fibrinous,  or 
(3)  purulent.  In  the  sero-fibrinous  form  there  is  little 
lymph,  the  exudate  being  mainly  composed  of  straw-colored 
serum  (a  few  ounces  to  several  pints),  which  in  favorable  cases 
is  gradually  absorbed. 

In  the  fibrinous  form,  serum  is  scant  and  the  membrane  is 
covered  with  a  butter-like  exudate,  which  subsequently  or- 
ganizes and  unites  more  or  less  closely  the  pericardial  surfaces, 
causing  adherent  pericardium.  The  adhesions  offer  resistance 
to  the  ventricular  contractions  and  ultimately  induce  cardiac 
hypertrophy.  In  rare  instances  the  fibrinous  exudate  becomes 
calcified. 

In  the  purulent  form,  death  usually  results ;  but  evacua- 
tion of  the  pus  may  be  followed  by  union  of  the  pericardial 
surfaces,  and  ultimate  recovery. 

Symptoms. — Moderate  fever,  precordial  pain  and  tender- 
ness, dry  cough,  dyspnoea,  and  palpitation.  The  pulse  is  at 
first  rapid  and  forcible,  but  later  weak  and  irregular. 

Physical  Signs.     First  Stage. — Dry  pericarditis. 

Inspection. — jS'egative. 

Palpation. — Sometimes  a  fremitus,  from  the  grating  of  the 
roughened  pericardial  surfaces. 

Percussion. — Negative. 


PERICARDITIS.  149 

Auscultation — A  superficial  to-and-fro  friction-sound,  usu- 
ally heard  best  at  the  base  of  the  heart  and  not  transmitted, 
to  any  extent,  beyond  the  prsecordia. 

Second  Stage. — Sero-fibriuous  effusion. 

Inspection. — Bulging  of  the  prsecordia. 

Palpation. — The  apex-beat  is  feeble  or  lost.  If  detected, 
it  is  pushed  upwards  and  to  the  left. 

Percussion. — Increased  area  of  dulness,  triangular  in  shape 
with  the  base  down. 

Auscultation. — The  heart-sounds  are  muffled,  feeble,  and 
distant. 

Purulent  effusion  yields  similar  signs,  but  in  addition, — 
(1)  the  symptoms  of  hectic  fever,  viz :  high  and  irregular 
fever,  sweats,  chills,  and  progressive  pallor.  (2)  Sometimes 
oedema  over  the  prsecordia ;  and,  (3)  in  doubtful  cases,  the 
aspirating  needle  reveals  pus. 

Fibrinous  pericarditis  (Adherent  pericardium)  is  often  diffi- 
cult to  recognize,  and  while  the  following  signs  suggest  the 
condition,  they  are  not  absolutely  diagnostic  : — 

Prsecordial  bulging,  a  weak  apex-beat  with  loud  sounds,  a 
systolic  retraction  or  dimpling  not  only  at  the  apex,  but  over  a 
large  part  of  the  pra3cordia,  a  peculiar  diastolic  collapse  of  the 
jugular  veins  (Friedreich),  a  feeble  apex-beat,  with  a  forcible 
impulse  over  the  body  of  the  heart  (Paul). 

With  these  signs  there  are  often  symptoms  of  heart- failure, 
such  as  dyspnoea,  dropsy,  and  cyanosis. 

Diagnosis.  Acute  Endocarditis. — The  murmur  is  soft  and 
blowing,  not  harsh  ;  it  is  usually  single,  not  to-and-fro  ;  it  is 
somewhat  distant,  not  superficial ;  it  is  not  necessarily  heard 
best  at  the  base,  but  at  one  of  the  valve  points ;  it  is  not  con- 
fined to  the  prsecordia,  but  is  usually  transmitted ;  and  it  is  not 
followed  by  the  signs  of  effusion. 

Pericardicd  effusion  must  be  distinguished  from  cardiac  hy- 
pertrophy. In  hypertrophy  the  area  of  dulness  is  increased, 
but  normal  in  outline ;  the  apex-beat  is  displaced  downwards 
and  to  the  left,  and  is  forcible ;  and  the  sounds  are  loud  and 
clear. 

Pericardial  effusion  and  cardiac  dilatation. — In  dilatation 
there  is  no  friction-sound ;  the  apex  is  usually  displaced  down- 


150  DISEASES    OF    THE   CIUCULATORY   SYSTEM. 

wards,  never  upwards ;  the  area  of  dnlness  is  not  pyramidal, 
but  extends  laterally;  the  sounds  are  not  muffled,  but  clear 
and  sharp. 

Prognosis. — In  the  dry  and  sero-fibrinous  forms  the  prog- 
nosis is  good  under  favorable  conditions.  In  the  purulent 
form  the  outlook  is  extremely  grave.  The  fibrinous  form, 
though  not  immediately  fatal,  is  very  serious  on  account  of  the 
secondary  changes  which  it  induces  in  the  cardiac  muscle. 

Treatment. — Absolute  rest.  Light  diet.  Opium  is  usu- 
ally required  to  insure  quiet  and  to  relieve  pain.  When  the 
action  of  the  heart  is  rapid  and  irregular,  either  aconite  or 
digitalis  may  be  administered  according  to  the  strength  of  the 
pulse. 

Local  Treatment. — In  severe  cases  apply  a  few  wet  cups, 
leeches,  or  a  blister  to  the  prsecordia.  In  other  cases,  an  ice- 
bag  or  poultice  may  give  relief. 

Pericardial  effusion  (Chronic  pericarditis), — When  the  effu- 
sion is  decided,  apply  small  blisters  over  the  prsecordia,  admin- 
ister iodide  of  potassium  (gr.  x  thrice  daily),  and  encourage 
diuresis  with  digitalis  or  caffeine,  and  catharsis  with  saline 
draughts. 

Paracentesis  of  the  pericardium  is  indicated  when  the 
effusion  is  large  and  causes  dyspnoea,  cyanosis,  and  a  weak, 
rapid  pulse,  and  when  the  exudate  is  purulent.  The  needle 
should  be  introduced  in  the  fifth  interspace,  a  little  to  the 
right  of  the  point  of  the  normal  apex-beat.  When  the 
effusion  is  purulent,  a  free  incision  offers  a  slight,  and  the 
only  chance  of  cure. 

In  adherent  pericardium,  repeated  small  blisters  may  be 
employed  and  heart-failure  combated  with  digitalis  and 
similar  cardiac  tonics. 


OTHER  AFFECTIONS  OF  THE  PERICARDIUM. 

Hydropericardium  (Dropsy  of  the  pericardium)  results  from 
pericarditis,  or  from  one  of  the  causes  of  general  dropsy,  as 
chronic  heart,  kidney,  or  lung  disease. 

Physical  Signs. — The  same  as  sero-fibrinous  pericarditis. 


ENDOCARDITIS,  151 

Hsemopericardium  (Blood  in  the  pericardial  sac)  results 
from  the  rupture  of  an  aneurism,  rupture  of  the  heart,  trau- 
matism, and  cancerous  and  tuberculous  pericarditis. 

Physical  Signs. — The  same  as  hydropericardium.  It  is 
speedily  fatal. 

Pneumopericardium  (Air  in  the  pericardium). — This  rare 
condition  results  from  external  wounds,  or  the  rupture  of  an 
air-containing  organ  into  the  pericardium,  as  the  perforation 
of  a  pyo-pneumothorax  into  the  pericardial  sac.  The  entrance 
of  a  septic  irritant  produces  pus  and  the  condition  becomes  a 
pneumo-pyopericardium. 

Physical  Signs. — Percussion  over  the  prsecordia  yields 
tympany  ;  and  auscultation,  splashing  and  metallic  sounds. 

ENDOCARDITIS. 

(Valvulitis.) 

Definition. — Inflammation  of  the  lining  membrane  of  the 
heart.     The  process  is  usually  contined  to  the  valves. 

Varieties. — (1)  Exudative,  cvr  vegetative  endocarditis 
(Endocarditis  verrucosa).  This  begins  as  an  acute  affection, 
but  usually  leads  to  chronic  interstitial  valvulitis.  (2)  Sclerotic, 
or  interstitial  valvulitis  (Chronic  endocarditis).  (3)  Ulcerative, 
or  malignant  endocarditis. 

Etiology. — Acute  endocarditis  usually  results  from  acute 
articular  rheumatism,  one  of  the  infectious  fevers,  chorea,  or 
septicaemia.  Gonorrhoea,  tuberculosis,  and  Bright's  disease 
are  occasional  causes.  At  least  40  per  cent,  of  all  cases  of 
acute  articular  rheumatism  are  complicated  with  endocarditis. 
The  young  are  more  liable  to  be  attacked  than  the  old. 
Sixty-two  of  73  fatal  cases  of  chorea,  collected  by  Osier, 
showed  endocarditis.  Of  the  infectious  fevers,  scarlatina 
and  pneumonia  are  most  prone  to  heart  complications. 

Chronic  endocarditis  may  be  congenital,  follow  an  acute 
attack,  or  result  directly  frona  alcoholism,  syphilis,  rheuma- 
tism, gout,  or  Bright's  disease.  Severe  muscular  strain  some- 
times induces  it. 

Pathology. — Post-natal  endocarditis  most  commonly 
involves  the  valves  of  the  left  side  of  the  heart. 


152  DISEASES   OF   THE   CIRCULATORY   SYSTEM. 

Pre-uatal  endocarditis  most  commonly  involves  the  valves 
of  the  right  side  of  the  heart. 

In  the  exudative  form  the  valve  is  red,  swollen,  lustreless, 
and  studded  with  numerous  bead-like  vegetations  which  are 
especially  marked  along  its  free  margins. 

These  vegetations  are  composed  of  proliferated  connective- 
tissue  cells,  the  superficial  layers  of  which  have  undergone 
coagulation-necrosis,  and  are  covered  with  more  or  less  fibrin 
derived  from  the  blood. 

They  may  be  whipped  ofiF  by  the  blood-current,  and  be 
carried  as  emboli  to  distant  organs,  as  the  brain,  kidney,  and 
spleen  ;  but  more  commonly,  if  life  is  preserved,  they  are 
partially  absorbed,  and  the  remaining  proliferated  connective- 
tissue  cells  form  fibrous  tissue,  and  thus  sclerotic  valvulitis  is 
secondarily  induced. 

Sclerotic  valvulitis  may  arise  as  a  primary  disease,  and  is 
characterized  by  thickening,  curling  and  puckering  of  the 
valve  from  an  overgrowth  of  fibrous  tissue,  which  is  often  as- 
sociated with  more  or  less  fatty  degeneration  of  the  cells  and 
a  deposition  of  lime  salts  in  their  midst. 

Symptoms  or  Acute  Endocarditis. — Subjective  phe- 
nomena are  often  absent,  and  auscultation  may  fui-nish  the 
only  indication  of  endocarditis,  namely,  a  prolongation  of  the 
heart-sound,  which  later  develops  into  a  distinct  murmur. 

In  many  cases  fever,  an  irregular  and  rapid  pulse,  palpita- 
tion, prsecordial  distress,  and  dyspnoea  are  associated  symp- 
toms. 

Diagnosis. — Chiefly  by  physical  signs.  In  "pericarditis  the 
friction-sound  is  to  and  fro,  superficial,  perliaps  modified  by 
pressure  of  the  stethoscope,  not  transmitted  much  beyond  the 
preecordia,  and  is  followed  by  signs  of  effusion. 

Prognosis. — In  simple  endocarditis  the  prognosis  should 
be  guarded.  The  lesion  rarely  disappears,  and  permanent 
damage  to  the  valve  results.  Under  favorable  conditions, 
however,  compensatory  hypertrophy  of  the  heart  results,  and 
good  health  may  be  preserved  for  an  indefinite  period. 

Treatment.— Absolute  rest  is  of  the  greatest  importance. 
The  original  disease  which  induced  the  endocarditis  should 
receive  appropriate  treatment.     The  application  of  blisters 


CHROXIC   VALVULAR   AFFECTIOXS.  153 

is  of  questionable  utility.  Cardiac  excitement  will  call  for 
digitalis  or  aconite,  according  to  the  strength  of  the  pulse. 
Heart-failure  must  be  combated  with  diffusible  stimulants, 
such  as  alcohol,  nitro-glycerine,  and  strychnine. 

CHRONIC  VALVULAR  AFFECTIONS. 

Period  of  Compensation. — By  compensation  is  meant  an  in- 
crease in  the  size  and  strength  of  certain  cardiac  chambers 
sufficient  to  enable  the  arterial  system  to  receive  its  normal 
amount  of  blood,  notwithstanding  obstruction  or  regurgitation 
at  one  or  more  of  the  valves. 

The  duration  of  this  period  is  indefinite,  and  depends  largely 
on  the  amount  of  damage  sustained  by  the  heart  and  the  hy- 
gienic conditions  to  which  the  patient  is  subjected. 

During  perfect  compensation  endocarditis  is  indicated  by 
physical  signs,  symptoms  being  entirely  absent. 

Aortic  Stenosis,  or  Aortic  Obstruction. 

Definition. — Obstruction  to  the  flow  of  blood  into  the 
aorta  from  thickening  or  adhesion  of  the  aortic  segments. 

Physical  Signs.  Inspection. — If  the  heart  is  strong,  the 
apex-beat  is  forcible,  and  is  noted  downward  and  to  the  left. 

Palpation  confirms  inspection,  and  sometimes  detects  a  sys- 
tolic thrill  at  the  base  of  the  heart. 

Percussion  may  yield  an  increased  ai'ea  of  cardiac  dulness, 
especially  to  the  left. 

Auscultation. — A_  systolic  murmur  with  maximum  intensity 
in  the  right  second  intercostal  space,  and  transmitted  into  both 
carotid  arteries. 

Pulse. — During  perfect  compensation,  the  pulse  is  quite 
normal,  but  when  the  heart  weakens,  it  becomes  small  and 
slow. 

Compensation. — From  obstruction  to  the  outflow  of  blood, 
the  left  ventricle  becomes  hypertrophied. 

Sequence. — Mitral  regurgitation.  Weakening  and  dilata- 
tion of  the  left  ventricle  prevent  perfect  closure  of  the  mitral 
orifice,  and  relative  insufficiency  results. 


154  DISEASES   OF   THE   CIRCULATORY  SYSTEM. 

Aortic  Insufficiency,  or  Aortic  Regurgitation. 

Definition. — Failure  of  the  aortic  valves  to  prevent  a  re- 
turn of  blood  to  the  ventricle,  from  rupture  or  inflammatory 
contraction  of  the  segments,  or  from  dilatation  of  the  orifice. 

Physical,  Signs.  Inspection. — Apex-beat  forcible,  and  dis- 
placed downward  and  to  the  left.     I'he  prsecordia  may  bulge. 

Palpation. — Confirms  inspection. 

Percussion. — Increased  area  of  cardiac  dulness,  especially  to 
the  left.  _  ... 

Auscultation. — A  diastolic  nuirmur  with  maximum  intensity 
in  the  right  second  intercostal  space,  and  transmitted  down  the 
sternum  and  towards  the  apex. 

Pulse. — The  arteries,  especially  the  carotids,  brachials,  and 
radials,  pulsate  visibly.  Palpation  detects  the  "  water-hammer," 
or  Corrigan's  pulse,  i.  e.,  a  short,  full,  and  receding  pulse. 

The  extreme  cardiac  enlargement  makes  the  pulse  full,  and 
the  prompt  leakage  back  into  the  ventricle  makes  it  short  and 
receding.  Elevation  of  the  arm,  during  palpation  of  the  radial, 
makes  this  pulse  more  apparent,  as  the  position  favors  regur- 
gitation. A  capillary  pulse  is  sometimes  present.  It  may  be 
noted  at  the  root  of  the  finger-nail  by  an  alternate  blushing 
and  paling,  synchronous  with  the  heart-beats. 

Compensation. — Dilatation  and  hypertrophy  of  the  left 
ventricle.  Dilatation  results  from  the  reception  of  such  a  large 
quantity  of  blood  during  diastole,  and  hypertrophy  follows 
from  the  increased  effort  which  the  ventricle  must  put  forth 
in  emptying  itself  of  this  extra  quantity  of  blood. 

This  extremely  dilated  and  hypertrophied  heart  has  been 
called  the  cor  bovinum,  or  ox-heart. 

Sequence.  —  Mitral  regurgitation.  The  dilatation  and 
weakening  of  the  ventricle  prevent  perfect  closure  of  the 
mitral  orifice,  and  relative  insufficiency  results. 

Mitral  Stenosis,  or  Mitral  Obstruction. 

Definition. — Obstruction  to  the  flow  of  blood  through  the 
mitral  orifice,  from  thickening  or  adhesion  of  the  mitral 
seo-ments. 


CHRONIC   VALVULAR   AFFECIIONS.  155 

Physical  Signs.  Inspection. — Apex-beat  is  not  much 
displaced.  There  is  sometimes  bulging  over  the  lower  part  of 
the  sternum. 

Palpation. — A  rough  presystolic  thrill  near  the  apex. 

Percussion. — Increased  area  of  dulness,  especially  to  the 
right. 

Auscultation.- — -A  prolonged,  rough,  churning  murmur, 
presystolic  in  time,  heard  most  distinctly  a  little  above  and 
to  the  left  of  the  apex,  and  not  transmitted. 

The  second  sound  at  the  pulmonary  cartilage  is  accentuated 
from  the  enlargement  of  the  right  ventrfcle. 

Pulse. — During  the  period  of  compensation  the  pulse  is 
small  and  regular. 

Compensation. — From  obstruction  to  the  outflow  of  blood 
the  left  auricle  becomes  enlarged ;  when  it  loses  power,  the 
blood  accumulates  in  the  lung,  and  to  overcome  this  pulmonary 
resistance  the  right  ventricle  becomes  hypertrophied. 

There  is  no  strain  on  the  left  ventricle,  and  hence  that  cham- 
ber is  not  enlarged. 

Sequence. — Tricuspid  regurgitation.  Dilatation  of  the 
right  ventricle  prevents  perfect  closure  of  the  tricuspid  orifice, 
and  relative  insufficiency  results. 

Mitral  Insufficiency,  or  Mitral  Regurgitation. 

Definition — ^Imperfect  closure  of  the  mitral  orifice  from 
rupture  or  inflammatory  contraction  of  the  mitral  segments  ;  or 
from  dilatation  or  weakening  of  the  left  ventricle,  preventing 
perfect  coaptation  of  normal  valves. 

Physical  Signs.  Inspection.  —  Apex-beat  forcible,  and 
noted  downward  and  to  the  left.     The  prsecordia  may  bulge. 

Palpation  confirms  inspection. 

Percussion. — Increased  area  of  dulness  to  the  right  and 
left. 

Auscultation. — A  systolic  murmur,  with  maximum  inten- 
sity at  the  apex,  and  transmitted  to  the  left  axilla  and  to  the 
angle  of  the  scapula. 

Pulse. — During  period  of  compensation  normal,  but  very 
irregular  when  the  heart  weakens. 


156  DISEASES   OF   THE   CIRCULATORY   SYSTEM. 

Compensation. — The  left  auricle  enlarges  from  the  extra 
amount  of  blood  that  it  receives ;  when  it  weakens,  the  lungs 
become  congested  and  right  ventricular  hypertrophy  follows. 

The  left  ventricle  also  becomes  hypertrophied  from  its  effort 
to  move  the  large  quantity  of  blood  which  it  receives  from  the 
distended  auricle  during  each  diastole. 

Sequence. — Tricuspid  regurgitation.  "Weakening  and  dila- 
tation of  the  right  ventricle  prevent  perfect  closure  of  the  tri- 
cuspid orifice. 

Tricuspid  Stenosis,  or  Tricuspid  Obstruction. 

This  lesion  is  comparatively  rare.  It  gives  rise  to  enlarge- 
ment of  the  heart  and  a  presystolic  murmur,  which  is  heard 
most  distinctly  at  the  xiphoid  cartilage. 

Tricuspid  Insufficiency,  or  Tricuspid 
Regurgitation. 

Definition. — Imperfect  closure  of  the  tricuspid  orifice 
from  inflammatory  shortening /3f  the' valves;  or,  more  com- 
monly, from  dilatation  of  tlie  right  ventricle  secondary  to 
mitral  disease  or  to  chronic  lung  disease. 

Physical  Signs. — Enlargement  of  the  heart ;  a  systolic 
murmur,  heard  most  distinctly  just  above  the  xiphoid  cartilage, 
and  associated  with  pulsation  of  the  jugular  vein,  and  in  bad 
cases,  with  pulsation  of  the  liver. 

Pulmonary  Stenosis,  or  Pulmonary  Obstruction. 

This  very  rare  lesion  is  always  congenital,  and  may  be  sus- 
pected when  a  systolic  murmur  is  heard  most  distinctly  at  the 
left  second  intercostal  space,  and  is  not  transmitted  into  the 
vessels  of  the  neck. 

Pulmonary  Insufficiency,  or  Pulmonary 
Regui'gitation. 

This  is  very  rare,  and  is  always  congenital.  It  produces  a 
diastolic  murmur,  which  is  heard  most  distinctly  in  the  left 
second  intercostal  space. 


CHRONIC    VALVULAR    AFFECTIONS.  157 

Period  of  Lost  Compensation. — Lost  compensation  nsu- 
ally  results  from  :  (1)  Increasing  damage  to  the  valves ;  (2) 
senility,  leading  to  arterial  and  cardiac  degeneration ;  (3) 
some  intercurrent  disease,  throwing  additional  strain  on  the 
heart ;  and  (4)  undue  physical  exertion. 

During  this  period  subjective  symptoms  appear.  In  car- 
diac insufficiency,  no  matter  what  the  original  valvular  lesion 
may  have  been,  the  organ  becomes  unable  to  fill  the  arteries, 
and  the  blood  is  dammed  back  in  the  lungs,  and  venous  con- 
gestion of  the  organs  follows. 

Symptoms. — Pulmonary  congestion  produces  dyspnoea, 
asthma,  heemoptysis,  and  often  chronic  bronchial  catarrh  with 
cough  and  expectoration. 

Hepatic,  stomachic,  and  intestinal  congestion  produce  dys- 
pepsia. Renal  congestion  produces  scanty,  albuminous  urine, 
and  later  nephritis. 

General  venous  congestion  produces  cyanosis,  and'  dropsy 
which  begins  in  the  feet  and  mounts  upward. 

Disturbances  of  the  cerebral  circulation  produce  headache, 
vertigo,  and  syncopal  attacks. 

In  aortic  disease,  especially  aortic  stenosis,  cerebral  symp- 
toms are  often  marked.  In  mitral  disease,  pulmonary  symp- 
toms are  usually  marked. 

Prognosis  of  Chronic  Valvular  Affections. — The 
extent  of  damage  can  never  be  accurately  determined  by  the 
quality  or  intensity  of  the  murmur. 

All  things  being  equal,  the  following  is  probably  the  order 
of  gravity  in  the  various  valvular  lesions  :  (1)  Tricuspid  re- 
gurgitation, (2)  aortic  I'egurgitation  (often  ending  in  sudden 
death),  (3)  aortic  stenosis,  (4)  naitral  stenosis,  and  (5)  mitral  re- 
gurgitation. 

The  following  are  unfavorable  conditions  :  Early  life,  ad- 
vanced years,  great  cardiac  enlargement,  irregular  heart-action, 
liability  to  recurring  attacks  of  rheumatism,  bad  hygienic 
surroundings,  and  symptoms  of  congestion  of  the  lungs,  kid- 
ney or  digestive  tract. 

In  proportion  to  the  absence  of  these  conditions,  the  prog- 
nosis becomes  favorable.  In  many  cases  life  is  not  materially 
shortened. 


158  DISEASES    OF   THE   CIRCUT.ATORY    SYSTEM. 

Treatment. — When  compensation  is  perfect,  the  treat- 
ment is  purely  hygienic. 

When  there  is  sudden  heart-failure  in  valvular  disease,  in- 
dicated by  orthopnoea  and  cyanosis,  rest  should  be  absolute, 
hot  aj)plications  should  be  applied  to  the  prsecordia,  and  diffu- 
sible stimulants  administered  hypodermically  :  spirits  of  am- 
monia (20-30  minims),  whiskey  (30-60  minims),,  sulphate 
of  strychnine  (gr.  -^,  repeated  once  or  twice),  and  especially 
nitro-glycerine  (1-2  drops  of  1  per  cent,  alcoholic  solution) 
may  be  so  employed  ;  the  last,  in  addition  to  being  a  highly 
diffusible  stimulant,  has  the  power  of  dilating  the  peripheral 
bloodvessels.  Venesection  (10-20  ounces)  is  often  of  consid- 
erable value  in  these  cases. 

When  compensation  is  gradually  lost,  rest,  a  light,  nutritious 
diet,  and  tinct.  digitalis  (10-20  drops  three  or  four  times  daily) 
are  the  most  important  therapeutic  measures.  Tinct.  strophan- 
sometimes  succeeds  when  digitalis  fails.  Mild  laxatives, 
such  as  massa  hydrargyri  (gr.  iij-v),  greatly  influence  the 
absorption  of  digitalis.  When  there  is  moderate  dropsy  the 
following  pill  is  very  efficient : — 

]^   Mass.  hydrargyri, 

Pulv.  digitalis, 

Pulv.  scillse,  aa  gr.  xxiv. — M. 
Ft.  in  pil.  ]Sro.  xxiv. 
Sig. — One  pill  thrice  daily. 

Strychnine  is  often  a  valuable  adjunct  to  digitalis,  especially 
when  there  are  indications  of  fatty  degeneration  of  the  heart. 
When  there  is  anaemia,  iron  is  indicated,  and  it  may  be  given 
with  digitalis  and  strychnine,  as  in  the  following  pill : — 

^   Strychnin,  sulph.,  gr.  j  ; 
Pulv.  digitalis, 

Perri  carb.  saccliar.,  aa  gr.  xxx. — M. 
Pt.  in  pil.  No.  xxx. 
Sig. — One  pill  thrice  daily. 

When  there  is  much  bronchitis  and  dyspnoea,  digitalis  with 
ammonia  and  senega  is  an  efficient  combination.  (Barlow.) 
When  dyspnoea  is  marked  and  the  pulse  is  strong,  nitro- 
glycerine (1-2  drops  thrice  daily,  or  gr.  ji^  thrice  daily),  if 
well  borne,  may  be  of  much   service.      In  extreme  dropsy 


ACUTE   ULCERATIVE   ENDOCARDITIS.  159 

free  catharsis  should  be  induced  by  compound  jalap  powder 

(gr.  xx-xxx),  or  a  concentrated  solution  of  Epsom  salts  (.Iss), 
and  diuresis  established  by  the  infusion  of  digitalis  (f 5  ss-f.lj, 
thrice  daily).  In  persistent  anasarca,  aspiration  of  serous  sacs 
and  puncture  of  the  legs  may  be  required. 

When  there  is  excessive  hypertrophy,  indicated  by  prjecor- 
dial  distress  and  a  full,  regular  pulse,  without  dropsy,  aconite, 
in  small  doses  will  prove  efficient. 

ACUTE  ULCERATIVE   ENDOCARDITIS. 

(Mycotic  Endocarditis,  Malig-nant  Endocarditis.) 

Definition. — A  rapidly-destructive  form  of  endocarditis, 
characterized  by  necrosis  or  ulceration  of  the  valves  and  the 
•deposition  of  colonies  of  micrococci. 

Etiology. — It  may  begin  as  a  primary  disease,  or  be 
engrafted  on  a  simple  endocarditis.  It  may  result  in  the  de- 
bilitated from  overwork  or  exposure ;  it  sometimes  complicates 
the  puerperium ;  it  generally  follows  septicaemia  or  one  of  tlie 
specific  fevers — such  as  pneumonia,  erysipelas,  and  scarlet 
fever.     It  may  be  induced  by  gonorrhoea. 

Pathology. — The  valves  are  the  seat  of  ulcers,  deep  ab- 
scesses, and  soft,  yellowish  vegetations,  which  have  undergone 
partial  necrosis.  Microscopic  examination  reveals  myriads  of 
micrococci. 

Symptoms.  1.  General. — High  and  irregular  fever,  re- 
peated chills,  profuse  sweats,  great  prostration,  often  delirium 
and  stupor,  hurried  breathing,  rapid  irregular  pulse,  brown 
fissured  tongue.    Jaundice  and  diarrhoea  are  frequently  present. 

2.  CarcUao  Symptoms.- — -Prsecordial  pain,  palpitation,  and 
often  a  blowing  murmur  at  one  or  more  of  the  valves.  Mur- 
murs may  be  absent. 

3.  JEmbolio  Symptoms. — Peripheral  emboli  yield  a  petechial 
rash  ;  renal  embolism  may  yield  bloody  urine ;  splenic  em- 
bolism may  yield  a  painful  spleen  ;  cerebral  embolism  may 
yield  paralysis. 

Diagnosis.  Ileningitis. — Cardiac  symptoms,  high  fever, 
profuse  sweats,  and  chills  will  usually  separate  it  from  men- 
ingitis. 


160  DISEASES    OF   THE    CIRCULATORY    SYSTE.M. 

Tyi^hoid  Fever. — Abrupt  onset,  cardiac  symptoms,  embolic 
symptoms,  sweats,  chills,  and  the  absence  of  the  character- 
istic rash,  of  the  Widal  reaction,  and  of  leucocytosis  will 
separate  it  from  typhoid  fever. 

Malarial  Fever. — In  endocarditis  the  plasmodium  malarice 
is  not  found  in  the  blood. 

Prognosis. — Almost  invariably  fatal.  Duration  is  from  a 
few  days  to  several  weeks. 

Treatment. — Ice-bags  to  the  heart.  Light  nutritious  diet. 
Stimulants. 

ACUTE  IMYOCAKDITIS. 

Definition. — Acute  inflammation  of  the  heart  muscle. 

Etiology. — It  is  almost  always  secondary  to  endocarditis 
or  to  pericarditis.  As  a  primary  affection  of  the  heart,  it 
may  be  due  to  rheumatism,  or  to  one  of  the  infectious  fevers. 

Pathology. — The  muscle  substance  is  pale,  flabby,  and 
friable.  Microscopic  examination  reveals  fatty  degeneration 
of  the  muscle  fibres  and  an  infiltration  of  the  connective  tis- 
sue with  leucocytes. 

Symptoms. — The  symptoms  are  often  masked  by  the  pri- 
mary disease.  Dyspnoea,  prsecordial  pain  and  distress,  a  weak, 
very  rapid,  small,  and  irregular  pulse,  a  feeble  impulse,  and 
weak  sounds  suggest  the  condition. 

Treatment. — Absolute  rest,  arrd  the  use  of  cardiac  stimu- 
lants, like  strychnine,  caffeine,  digitalis,  and  alcohol. 

FIBROID  HEART. 

(Myo-degeneration  of  the  Heart,  Chronic  Myocarditis,  Indurated 
Degeneration.) 

Etiology. — -This  condition  is  dependent  upon  atheroma  or 
sclerosis  of  the  coronary  arteries.  The  indirect  causes  are 
rheumatism,  gout,  syphilis,  alcoholism,  endocarditis  and  peri- 
carditis. 

Pathology. — The  heart  is  usually  hypertrophied  or 
dilated,  and  is  the  seat  of  grayish-white  patches,  M'hich  repre- 
sent overgrown   connective   tissue.      The  papillary  muscles. 


HYPERTROPHY    OF   THE    HEART.  161 

columnse  carnese,  and  the  wall  of  the  left  ventricle  near  the 
apex  are  the  parts  most  frequently  affected. 

Arterial  sclerosis  causes  necrosis,  and  this  in  turn  is  followed 
by  a  proliferation  of  the  connective  tissue. 

The  fibroid  areas  sometimes  yield  to  the  endocardial  pres- 
sure and  cause  aneurism  of  the  heart. 

Symptoms. — It  manifests  the  same  symptoms  as  fatty  de- 
generation, viz :  dyspnoea,  cough,  weak  and  irregular  pulse, 
palpitation,  anginoid  pains,  dropsy,  etc. 

Treatment. — Same  as  in  fatty  heart. 

HYPERTROPHY  OF  THE  HEART. 

Definition. — Enlargement  of  the  heart  due  to  an  over- 
growth of  its  muscle. 

"  Etiology. — It  always  results  from  increased  work,  and 
this  may  be  due  to :  (1)  Too  much  blood  to  be  moved  from 
the  heart,  as  in  the  regurgitant  valvular  lesions.  (2)  Obstruc- 
tion to  the  outflow  of  blood  at  the  valves,  as  in  the  stenoses ;  or 
in  the  pulmonary  or  the  systemic  circulation,  as  in  emphysema 
and  Bright's  disease.  (3)  Resistance  to  ventricular  contrac- 
tion by  pericardial  adhesions.  (4)  Undue  physical  exertion 
long  continued.  (5)  Disturbed  innervation  from  drugs,  such 
as  tobacco ;  or  from  disease,  as  exophthalmic  goitre. 

Varieties. — (1)  Simple  hypertrophy.  Thickened  muscle 
and  cavities  of  normal  size.  (2)  .Eccentric  hypertropjhy  (hyper- 
trophy with  dilatation).  Thickened  muscle  and  cavities  di- 
lated. (3)  Concentric  hypertropjhy.  Thickened  muscle  and 
cavities  diminished  in  size.     Always  congenital. 

Pathology. — The  average  weight  of  the  normal  heart  is 
eight  or  nine  ounces  ;  in  hypertrophy  it  may  weigh  two  or 
three  times  as  puch.  One  or  both  ventricles  may  be  en- 
larged ;  the  left  is  the  one  more  commonly  affected.  The 
muscle  is  firm  and  of  a  deep-red  color.  Histologically  the 
muscle-elements  are  increased  in  size  and  number. 

Symptoms. — Unless  the  hypertrophy  is  more  than  compen- 
satory no  symptoms  result.     Extreme  hypertrophy  is  indicated 
by  preecordial  distress,  palpitation,  a  strong  pulse,  and  some- 
times by  the  phenomena  of  cerebral  hypersemia,  viz  :    flushed 
11 


162  DISEASES    OF   THE    CIRCULATORY    SYSTEM. 

face,  ringing  in  the  ears,  flashes  of  light,  headache,  and  dis- 
turbed sleep. 

Physical  Signs.  Inspection. — Prsecordial  bulging.  For- 
cible impulse.  The  apex-beat  is  displaced  downward  and  to 
the  left. 

Palpation. — A  heaving  impulse. 

Percussion. — Increased  area  of  cardiac  dulness. 

Auscultation. — Sounds  are  dull  and  loud. 

Sequelje. — Apoplexy,  fatty  degeneration  of  the  heart  and 
subsequent  dilatation,  valvular  disease,  and  arterial  degeneration. 

Diagnosis. — Hypertrophy  and  dilatation.  These  two  con- 
ditions are  commonly  associated,  but  the  preponderance  of  di- 
latation will  be  indicated  by  a  feeble  fluttering  impulse,  weak 
sounds,  a  weak,  irregular,  or  intermittent  pulse,  and  by  symp- 
toms of  heart-failure,  such  as  dyspnoea,  dropsy,  etc. 

Treatment. — When  the  hypertrophy  is  excessive,  recom- 
mend graduated  exercise  and  a  light  diet,  and  employ  such  seda- 
tives as  tincture  of  aconite  (gtt,  j— ij  thrice  daily)  or  tincture  of 
veratrum  viride  (gtt.  j-ij).  The  bromides  are  often  valuable 
adjuncts. 

DILATATIOX  OF  THE  HEART. 

Definition. — Enlargement  of  the  heart  due  to  stretching 
of  its  walls. 

Varieties. — (1)  Dilatation  with  thickening  of  the  walls 
(eccentric  hypertrophy),  and  (2)  Dilatation  with  thinning  of 
the  walls. 

Etiology. — Dilatation  results  from  excessive  endocardial 
pressure,  as  in  sudden  extreme  exertion  and  in  valvular  disease, 
and  (2)  Impaired  nutrition  of  the  cardiac  muscle,  as  in  low 
fevers,  valvular  disease,  and  atheroma  of  the  coronary  arteries. 

Pathology. — One  or  both  ventricles  maV  be  dilated ;  the 
right  is  the  one  more  commonly  aifected.  The  condition  is 
usually  associated  with  hypertrophy  and  fatty  degeneration. 
The  muscle  may  be  normal  in  appearance,  but  very  fre- 
quently it  is  pale  and  soft. 

Symptoms. —  So  long  as  the  associated  hypertrophy  keeps 
pace  with  the  dilatation,  no  symptoms  result;  but  when 
dilatation  preponderates  the  following  symptoms  of  venous 


FATTY   DEGENERATION    OF   THE    HEART.  163 

stasis  appear  :  dyspnoea,  cough,  dyspepsia,  scanty  urine,  dropsy, 
and  a  feeble,  irregular  pulse. 

Disturbed  innervation  often  causes  preecordial  distress  and 
palpitation. 

Physical  Signs. — Apex-beat  is  diffuse  and  weak  ;  it  may 
be  visible  and  yet  not  palpable  (Walshe).  "When  the  right 
heart  is  involved  an  impulse  is  noted  below  the  xiphoid  carti- 
lage. 

Palpation. — A  diffuse,  feeble,  and  fluttering  impulse. 

Percussion. — The  area  of  dulness  is  increased,  especially 
la/"erally. 

Auscultation. — The  sounds  are  weak  and  sharp.  The  first 
sound  loses  its  muscular  element  and  resembles  the  second. 
Co-existing  valvular  lesions  induce  murmurs. 

Diagnosis. — Pericardial  effusion.  In  this  condition  a  fric- 
tion-sound is  frequently  present ;  the  outline  of  dulness  is  py- 
riform  with  the  base  below,  is  not  nearly  so  broad  as  in  dila- 
tation, the  sounds  are  distant  and  muffled,  and  the  apex-beat 
is  dilated  upwards. 

TreaTxMEXT. — Eest.  Light  and  nutritious  diet.  Improve 
the  general  condition  by  careful  hygienic  regulations,  and  the 
use  of  such  tonics  as  iron,  quinine,  arsenic,  and  the  like.  Car- 
diac tonics,  as  digitalis,  caffeine,  strophanthus,  and  strychnine, 
are  indicated. 

In  sudden  dilatation,  use  diffusible  stimulants,  as  brandy, 
ammonia,  or  strychnine,  hypodermically. 

FATTY  DEGEjVERATIOX  OF  THE  HEART. 

Definition. — The  term  fatty  heart  is  applied  to  (1)  fatty 
infiltration,  in  which  an  abnormal  amount  of  fat  is  deposited  in 
and  upon  the  heart ;  and  (2)  to  fatty  degeneration,  in  which 
the  cardiac  muscle  has  been  metamorphosed  into  fat. 

Fatty  Infiltration. 

Etiology. — It  is  a  part  of  general  obesity,  and  hence  re- 
suits  from  an  hereditary  tendency,  a  rich  diet,  and  sedentary 
habits. 


164  DISEASES   OF   THE   CIRCULATORY   SYSTEM. 

Pathology. — The  heart  may  be  completely  imbedded  in 
fat,  the  grooves  along  the  larger  bloodvessels  being  favorite 
seats  of  deposit.  Fat  is  also  found  between  the  muscle  fibres, 
although  tlie  latter  may  be  perfectly  normal. 

Symptoms. — Shortness  of  breath  increased  by  exerti'on,  a 
weak  but  regular  pulse,  prsecordial  distress,  a  tendency  to  pul- 
monary congestion,  with  a  resulting  obstinate  bronchitis,  and 
sluggish  digestion. 

Prognosis. — Favorable. 

Treatment. — -A  regulated  diet,  in  which  the  use  of  fats, 
starches,  and  sugars  is  restricted.  Graduated  exercise.  The 
Turkish  bath  under  supervision.  Heart  tonics,  like  digitalis 
and  strychnine,  are  sometimes  indicated. 

Fatty  Degeneration  of  the  Heart. 

Etiology. — (1)  It  follows  hypertrophy  in  valvular  disease. 

(2)  It  is  frequently  due  to  atheroma  of  the  coronary  artery. 

(3)  It  is  a  common  result  of  malnutrition  from  old  age,  wast- 
ing disease,  or  ansemia.  (4)  It  is  associated  with  parenchyma- 
tous degeneration  in  the  infectious  fevers.  (5)  It  results  from 
mineral  poisoning,  as  by  arsenic,  antimony,  phosphorus. 

Pathology. — The  muscle  is  pale,  soft,  and  flabby,  and 
feels  greasy  to  the  hand.  Microscopic  examination  reveals  a 
deposition  of  granular  fat  in  the  muscle-fibres. 

Symptoms. — When  the  condition  is  marked,  it  is  charac- 
terized by  all  the  symptoms  of  heart-failure,  namely,  dys- 
pnoea, asthma,  cough,  a  weak,  irregular  pulse,  which  may  be 
quite  rapid  or  unusually  slow,  poor  digestion,  weak  heart- 
sounds,  a  feeble  apex-beat,  dropsy,  attacks  of  syncope,  and, 
near  the  end,  Cheyue-Stokes  breathing. 

Disturbed  innervation  often  causes  palpitation,  prsecordial 
distress,  and  attacks  of  angina  pectoris. 

There  may  be  associated  evidences  of  atheroma,  namely, 
rigid  arteries,  and  in  the  cornea,  a  fatty  arcus  senilis. 

Prognosis. — Unfavorable.  Death  may  occur  suddenly  on 
sliglit  exertion. 

Treatment. — Rest  of  mind  and  body.  A  carefully-regu- 
lated  diet,    which,   should   be    light   but    nutritious.      Iron, 


ANGINA   PECTORIS.  165 

quinine,  and  arsenic  are  sometimes  indicated.  In  this  condi- 
tion strychnine  (gr.  qq—^q  thrice  daily)  is  often  of  great  value. 
Nitro-glycerine  (gr.  yJ-q-  or  one  minim  of  the  one  per  cent, 
thrice  daily)  may  relieve  the  distressing  symptoms.  Restless- 
ness, prsecordial  distress,  and  insomnia  will  call  for  morphine. 
In  angina,  hot  applications  should  be  applied  to  the  prsecor- 
dia,  and  nitrite  of  amyl  administered  by  inhalation. 

ANGINA  PECTORIS. 

(Neuralgia  of  the  Heart,  Stenocardia.) 

Definition. — A  symptomatic  affection  most  commonly 
associated  with  occlusion  of  the  coronary  arteries  and  degen- 
eration of  the  myocardium,  and  characterized  by  severe  par- 
oxysmal pain  in  the  region  of  the  heart. 

Etiology. — It  usually  develops  after  middle  life,  and  is 
more  common  in  men  than  women.  The  predisposing  causes 
are  those  of  arteriosclerosis — i.e.,  alcoholism,  gout,  syphilis, 
and  Bright's  disease.  In  some  instances  an  hereditary  ten- 
dency has  been  noted,  and  not  infrequently  the  attacks  have 
been  preceded  by  prolonged  mental  anxiety. 

False  angina  {pseudo-angina  pectoris)  is  sometimes  asso- 
ciated with  hysteria,  reflex  irritation,  or  the  excessive  use  of 
tobacco. 

Pathology. — Obstruction  of  the  coronary  arteries  from 
atheroma  or  thrombosis,  with  resultant  degeneration  of 
the  cardiac  muscle,  is  the  condition  usually  found  after 
death. 

Symptoms. — The  attacks  are  usually  precipitated  by 
emotional  or  physical  excitement  or  indigestion,  and  are 
characterized  by  severe  pain,  radiating  from  the  heart  to  the 
shoulder  and  down  the  arm  (usually  the  left),  a  pale,  anxious 
face,  a  sense  of  im})ending  death,  dyspnoea,  and  fixation  of 
the  body.     The  pulse  is  very  variable. 

The  attacks  last  from  a  few  seconds  to  several  min- 
utes, and  may  recur  at  intervals  of  a  few  days  to  several 
years. 

Diagnosis.  Gastralgia. — The  pain  does  not-  radiate  to 
the  shoulder  and  thence  down  the  arm  ;  there  is  no  fear  of 


166  DISEASES   OF   THE   CIRCULATORY   SYSTEM. 

approaching  death,  and  no  fixation  of  the  body  ;  the  attack 
usually  appears  when  the  stomach  is  empty ;  there  is  no  evi- 
dence of  organic  heart  disease. 

Pseudo-angina,  or  Hysterical  Angina.- — This  affection  occurs 
chiefly  in  women  of  a  neurotic  temperament;  is  unassociated 
with  organic  heart  disease ;  usually  occurs  at  night ;  rarely 
induces  fixation  of  the  body ;  is  of  longer  duration  than  true 
angina ;  and  is  associated  with  emotional  excitement. 

Prognosis. — Grave.     Sudden  death  is  to  be  expected. 

The  duration  is  often  long,  and  in  some  instances  recovery 
follows.  The  prognosis  is  more  favorable  when  the  paroxysms 
are  mild,  infrequent,  unassociated  with  organic  lesions,  and 
brought  on  by  exertion. 

Treatment.  The  Attach. — Inhalation  of  nitrite  of  amyl 
(a  few  drops  on  a  handkerchief)  and  hot  applications  to  the 
prsecordia.  If  prompt  relief  does  not  follow,  morphine  sul- 
phate (gr.  ^)  with  atropine  sulphate  (gr.  y2"o")  ^^Y  ^®  given 
hypoderniically. 

The  Interval. — Rest  of  body  and  mind.  A  carefully-regu- 
lated diet,  which  should  be  light  but  nutritious. 

Iodide  of  potassium  (gr.  x  thrice  daily)  over  a  long  course 
has  been  highly  recommended. 

Nitroglycerine  (gr.  y^^  to  -^-q)  when  well  borne  is  some- 
times extremely  useful  in  warding  oif  the  attacks.  Patients 
may  be  provided  with  glass  capsules  of  nitrite  of  amyl. 
General  tonics,  like  strychnine,  iron,  and  arsenic,  are  often  indi- 
cated. 

AKEURISM  OF  THE  AORTA. 

Definition. — A  circumscribed  dilatation  of  the  aorta. 

Etiology. — The  male  sex,  middle  life,  and  laborious  work 
are  general  predisposing  factors.  The  conditions  which  lead 
to  arterial  degeneration,  like  syphilis,  rheumatism,  gout,  and 
alcoholism,  are  potent  predisposing  causes. 

Sudden  exertion  is  commonly  the  exciting  cause. 

Pathology. — Aneurisms  are  divided  according  to  shape 
into  the  fusiform,  saccular,  and  cylindrical  forms.  When  all 
the  arterial  tunics  have  yielded,  the  dilatation  is  termed  a  true 


ANEUEISM   OF   THE   AORTA.  167 

aneurism  ;  when  the  internal  tunic  alone  has  ruptured,  and 
blood  has  escaped  between  the  layers,  it  is  termed  a  false  or 
dissecting  aneurism. 

A  true  aneurism  is  composed  (1)  of  an  external  or  adven- 
titious sac  which  results  from  inflammation  and  condensation 
of'tlie  surrounding  connective  tissue;  (2)  of  one  or  more  of 
the  degenerated  coats  of  the  vessel;  and  (3)  of  a  clot,  which  is 
often  firm  and  laminated. 

The  arch  of  the  aorta  is  the  most  common  seat.  About  ten 
per  cent,  of  aortic  aneurisms  are  abdominal. 

Thoracic   Aneurism. 

Physical  Signs.  Inspection. — This  often  detects  an  abnor- 
mal prominence  and  pulsation  in  the  upper  sternal  region. 

Dilatation  of  the  superficial  veins  may  also  be  noted,  and 
in  advanced  cases  the  skin  over  the  prominence  may  be  red 
and  glossy. 

Palpation. — This  often  detects  an  expansile  pulsation  and 
a  systolic  thrill. 

If  the  cricoid  cartilage  is  grasped  between  the  fingers  and 
thumb,  and  drawn  upwards,  a  pulsation  or  tug  may  be  trans- 
mitted to  the  trachea. 

Percussion. — This  occasionally  reveals  circumscribed  dul- 
ness  and  increased  resistance. 

Auscultation. — If  the  clot  is  not  too  large,  the  ear  may 
detect  a  systolic  bruit  or  murmur.  Accentuation  of  the  heart- 
sounds  is  often  noted. 

-Pulse. — The  pulse  in  one  radial  may  be  delayed,  and  dimin- 
ished in  volume  from  the  diffusion  or  spending  of  the  current 
within  the  sac,  or  from  the  partial  occlusion  of  the  arterial 
orifice. 

Symptoms.  —  Dyspnoea  results  from  pressure  upon  the 
trachea,  bronchi,  or  recurrent  laryngeal  nerve,  the  last  causing 
spasm  or  paralysis  of  the  vocal  cords.  Cough  is  rarely  absent, 
and  when  due  to  spasm  of  the  vocal  cords  it  is  of  a  metallic, 
barking  character. 

Pain  frequently  results  from  pressure  on  the  bones — ver- 
tebrae and  sternum,  or  from  irritation  of  neighboring  nerves. 


168  DISEASES   OP   THE   CIRCULATORY   SYSTEM.     - 

Dilatation  or  contraction  of  one  pupil  may  result  from  pres- 
sure on  tiie  cervical  sympathetic,  and  unilateral  sweating  of  the 
face  is  sometimes  induced  by  the  same  cause. 

Difficult  swallowing  (dysphagia)  results  from  pressure  on 
the  oesophagus ;  and  dilatation  of  the  superficial  veins,  cyano- 
sis, and  local  oedema  may  result  from  pressure  upon  the  deep- 
seated  veins. 

Diagnosis. — A  solid  tumor  may  yield  a  transmitted  pulsa- 
tion and  simulate  aneurism,  but  in  the  former  the  pulsation  is 
up  and  down,  not  expansile,  the  impact  is  less  pronounced, 
the  bruit  is  usually  absent,  the  heart-sounds  are  not  accentu- 
ated, there  is  no  tracheal  tug,  and  the  health  is  generally  more 
impaired. 

Pulsating  Empyema. — A  left-sided  purulent  effusion  may 
transmit  a  cardiac  pulsation,  but  the  latter  is  not  expansile, 
the  dulness  is  diffuse,  the  bruit  is  absent,  and  the  history  will 
suggest  pleurisy. 

An  expansile  aorta  may  simulate  aneurism.  This  condi- 
tion usually  occurs  in  women  of  a  neurotic  temperament,  and 
lacks  the  bruit  and  pressure-symptoms. 

Prognosis. — Always  grave.  The  average  duration  is  from 
one  to  two  years.  Death  may  result  (1)  from  rupture  exter- 
nally, or  internally  into  the  pericardium,  heart,  pleural  sac, 
bronchi,  lung,  or  oesophagus  ;  (2)  from  exhaustion  ;  (3)'  from 
heart-failure,  for  sometimes  the  aneurism  dilates  the  aortic  ori- 
fice and  thereby  causes  aortic  insufficiency. 

Treatment. — Mechanical  treatment  by  ligation  of  distal 
arteries,  acupuncture,  and  electrolysis,  has  not  only  been  un- 
satisfactory, but  has  often  shortened  life. 

The  treatment  commonly  employed  is  a  modification  of 
Tufnell's  method,  and  consists  in  absolute  rest  in  bed  for  from 
eight  to  twelve  weeks,  M'ith  a  dry  diet,  and  the  administration 
of  iodide  of  potassium,  which  is  used  empirically  in  doses  of 
ten  to  twenty  grains,  thrice  daily.  When  the  pulse  is  very 
strong,  heart  sedatives  like  aconite  and  veratrum  viride  may 
be  administered,  or  venesection  cautiously  practised.  Pain  is 
often  temporarily  relieved  by  the  iodide,  but  when  it  is  severe 
an  ice-bag  may  be  applied  locally  and  morphine  given  hypoder- 
mically. . 


AETERIO-SCLEROSIS.  169 

ft 

Aiieui'ism  of  the  Abdominal  Aorta. 

Seat — It  is  most  frequently  located  near  the  coeliac  axis. 

Symptoms. — It  may  be  recognized  by  sharp  pain  in  the 
back,  radiating  along  the  spinal  nerves,  and  increased  by  eat- 
ing and  drinking,  by  a  delay  in  the  femoral  pulse,  by  gastro- 
intestinal symptoms,  and  by  physical  signs  similar  to  those  of 
thoracic  aneurism. 

Diagnosis. — An  abdominal  cancer  may  receive  a  pulsation 
from  the  aorta,  and  simulate  aneurism,  but  in  the  former,  pul- 
sation is  not  expansile,  and  is  frequently  lost  Avhen  the  patient 
is  placed  in  the  knee-breast  posture ;  and  there  is  greater 
cachexia,  and  gastro-intestinal  disturbance. 

The  pulsating  aorta  of  nervous  women  may  simulate  aneu- 
rism, but  there  are  no  pressure-symptoms,  or  distinct  tumor, 
and  it  is  in  the  sex  in  which  abdominal  aneurisms  are  very  un- 
common. 

Prognosis. — Very  grave.  Death  usually  results  from 
rupture. 

Treatment. — Same  as  in  thoracic  aneurism.  Compression 
of  the  aorta,  the  patient  having  been  anaesthetized,  has  given 
good  results. 

ARTERIO-SCLEROSIS. 

(Atheroma,  Gull  and  Sutton's  Disease.) 

Definition. — A  thickening  of  the  arteries  due  to  an  over- 
growth of  connective  tissue,  associated  with  more  or  less  fatty 
degeneration  and  calcification. 

Etiology. — Old  age,  gout,  rheumatism,  alcoholism,  syph- 
ilis, lead-poisoning,  nephritis,  and  laborious  work  are  predis- 
posing causes. 

Pathology. — The  arteries  are  thickened,  tortuous,  and 
rigid.  The  intima  reveals  roughened  and  opaque  areas,  which 
are  often  the  seat  of  calcareous  deposits.  In  extreme  cases 
there  may  be  spots  of  necrotic  softening  in  the  subendothelial 
tissue,  forming  "  atheromatous  abscesses."  Microscopic  ex- 
amination shows  more  or  less  fatty  degeneration  of  the  different 
coats,  and  an  overgrowth  of  connective  tissue  in  the  intima. 


170  DISEASES    OF    THE    CIRCULATORY   SYSTEM. 

Symptoms.  Circulatory  Phenomena. — Rigidity  of  the  pe- 
ripheral vessels,  a  sluggish,  high-tension  pulse,  accentuation  of 
the  second  aortic  sound,  palpitation,  dyspncea,  anginoid  pains, 
and  hypertrophy  of  the  left  ventricle. 

Renal  Phenomena. — The  urine  is  increased  in  quantity,  is 
pale  in  color,  and  of  low  specific  gravity.  It  may  contain  a 
trace  of  albumin  and  a  few  hyaline  casts. 

Cerebral  Phenomena. — Headache,  vertigo,  disturbed  sleep, 
failure  of  memory,  and  tinnitus  aurium. 

Sequels. — Cerebral  congestion,  apoplexy,  fatty  heart,  di- 
latation of  the  heart,  angina  pectoris,  aneurism,  interstitial 
nephritis,  gangrene  of  the  extremities. 

Treatment. — A  careful  i-egulation  of  the  habits,  clothing, 
and  diet.  Stimulants  must  be  avoided.  Iodide  of  potassium 
(gr.  V  thrice  daily)  has  been  recommended  for  its  absorbent 
effect.  Nitroglycerine  is  sometimes  valuable  in  overcoming 
the  high  arterial  tension. 


DISEASES 


RESPIRATORY  SYSTEM, 


THE  NOSE. 


The  Red  Nose. — A  nose  which  is  permanently  and  uni- 
formly red  generally  indicates  alcoholism  or  acne  rosacea.  A 
nose  which  is  permanently  red  and  swollen  at  the  extremities, 
and  has  a  broadened  bridge,  indicates  chronic  hypertrophic 
rhinitis. 

Flattening  of  the  Bridge. — This  may  result  from  trauma- 
tism or  tertiary  syphilis. 

Movement  of  the  Alse  Nasi  during  Respiration. — Playing 
of  tlie  alse  is  occasionally  noted  in  health,  but  it  is  generally 
an  indication  of  some  obstruction  to  the  entrance  of  air.  It  is 
frequently  observed  in  spasmodic  croup,  true  croup,  laryngeal 
oedema,  capillary  bronchitis,  and  pneumonia. 

Nasal  Discharge. — Temporary  "running  from  the  nose"  is 
a  symptom  of  acute  coryza,  measles,  hay-fever,  diphtheria, 
and  influenza.  An  offensive  discharge  should  suggest  nasal 
diphtheria,  or  the  impaction  of  a  foreign  body. 

ChroniG  discharge  occurs  in  chronic  rhinitis.  In  infants, 
chronic  nasal  discharge  with  mouth-breathing  ("  snuffles")  is 
very  suggestive  of  hereditary  syphilis. 

The  Sense  of  Smell. — This  is  tested  by  holding  odoriferous 
substances  before  one  nostril  at  a  time  while  the  other  is  closed. 
Pungent  vapors  should  be  avoided,  as  the  irritation  which 
they  excite,  and  not  their  odor,  mav  lead  to  their  recognition. 

(171) 


172  DISEASES   OP   THE   RESPIRATORY  SYSTEM. 

The  sense  of  smell  is  impaired  or  lost  (anosmia)  from  : — 

1.  Rhinitis  or  morbid  growths. 

2.  Aflfections  of  the  anterior  part  of  the  brain,  involving 
the  olfactory  nerves  or  bulbs — as  injury,  tumor,  meningitis. 

3.  Lesions  of  the  olfactory  centres. 

4.  Paralysis  of  the  trigeminal  nerve  (by  inducing  dryness 
of  the  mucous  membrane). 

5.  Old  age. 

An  increase  (hyperosmia)  or  a.  perversion  (parosmia)  of  the 
sen^e  of  smell  may  "occur  in  hysteria,  insanity,  and  as  an  aura 
of  epilepsy. 

Epistaxis. — Hemorrhage  from  the  nose  occurs  under  the 
following  conditions :  (1)  Traumatism.  (2)  Inflammation. 
(3)  Obstructed  circulation — as  in  chronic  heart,  lung,  and  liver 
disease.  (4)  Blood-dyscrasia — as  in  scurvy,  infectious  fevers, 
haemophilia,  and  purpura.  (5)  Onset  of  fevers,  especially 
typhoid.  (6)  Vicarious  menstruation.  (7)  In  rarefied  atmo- 
sphere, as  in  mountain-climbing.  (8)  Often  without  obvious 
cause. 

THE   LARYNX. 

Spasm  of  the  laryngeal  adductors  is  characterized  by  intense 
dyspnoea  and  occurs  in  spasmodic  croup;  in  true  croup;  in 
ulceration  of  the  larynx  ;  in  laryngismus  stridulus ;  in  whoop- 
ing-cough ;  in  tetany  ;  in  hysteria ;  in  hydrophobia  ;  in  the 
laryngeal  crisis  of  locomotor  ataxia ;  when  foreign  bodies  have 
lodged  in  the  larynx ;  and  when  aneurisms  or  mediastinal 
tumors  press  on  the  recurrent  laryngeal  nerve  and  irritate  it. 

Aphonia  or  loss  of  voice  may  occur : — 

1.  In  severe  inflammation  of  the  larynx. 

2.  From  hysteria. 

3.  In  centric  paralysis  of  the  recurrent  laryngeal  nerves,  as 
in  bulbar  palsy  and  in  tumors  of  the  medulla. 

4.  In  perijjheral  paralysis  of  the  recurrent  laryngeal  nerve 
caused  by  the  pressure  of  an  aneurism,  mediastinal  tumor,  or 
pericardial  effusion. 

5.  From  prolonged  use  of  the  voice. 

6.  From  the  lodgment  of  foreign  bodies. 

7.  From  cicatricial  stenosis  of  the  larynx. 


RESPIEATION. 


173 


Paralysis  of  the  Laryngeal  Muscles. 


Paralysis  of  all 
of  the  muscles. 


Complete  uni- 
lateral paraly- 
sis. 


Complete  par- 
alysis of  the 
abductors. 

Unilateral  par- 
alysis of  the 
abductors. 

Complete  par- 
alysis of  the 
adductors. 


Causes. 
Hysteria ;  bulbar  pal- 
sy ;      pressure     upon 
both  vagi  or    spinal 
accessories. 

Pressure  upon  one  re- 
current laryngeal  by 
an  aneurism  or  tu- 
mor. 


Catarrhal  laryngitis ; 
bulbar  palsy ;  pres- 
sure on  both  vagi  or 
recurrents ;  hysteria. 

Pressure  on  one  recur- 
rent by  an  aneurism 
or  mediastinal  tumor. 

Hysteria ;  laryngitis  ; 
prolonged  use  of  the 
voice. 


Symptoms. 
Aphonia,  but  no  cough 
or  dyspnoea. 


Voice  weak  and  rough; 
no  cough  or  dyspncea. 


Voice  quite    natural ; 

inspiratory      stridor 

and     dyspnoea;      no 

cough. 
Hoarseness ;       fatigue 

after  moderate  use  of 

the  voice ;  slight  dys- 

pncea. 
Aphonia,  but  no  cough 

or  dyspnoea. 


Laryngoscopic 

APPEAEAN'CE. 

The  cords  are  midway 
between  adduction 
and  abduction,  and 
are  motionless  ("  cad- 
averic position"). 

One  cord  is  moder- 
ately abducted  and 
motionless ;  the  other 
is  drawn  beyond  the 
median  line'  in  pho- 
nation. 

The  cords  are  near  to- 
gether, and  brought 
still  closer  by  inspi- 
ration. 

One  cord  is  near  the 
median  line,  and  is 
motionless  on  inspi- 
ration. 

Cords  are  open  and 
move  naturally  on 
respiration,  but  are 
motionless  during  at- 
tempted phonation. 


RESPIRATION. 

Dyspnosa. — Dyspnoea  implies  difficult  breathing  with  or 
without  an  increase  in  the  number  of  respirations.  Dyspnoea 
which  is  so  severe  as  to  necessitate  a  sitting  posture  is  termed 
orthopnoea.  Dyspnoea  may  occur  on  inspiration,  expiration,  or 
both. 

Dyspnoea  on  expiration  is  chiefly  noted  in  pulmonary  emphy- 
sema and  asthma. 

Dyspnoea  on  inspiration,  or  on  both  inspiration  or  expira- 
tion. In  this  form  the  base  of  the  chest  is  retracted  during 
the  violent  inspiratory  efforts. 

Ms  chief  causes  are  :  (1)  Obstruction  in  the  larynx  from 
spasm,  paralysis,  false  membrane,  oedema,  or  a  foreign  body. 
(2)  Pressure  of  an  aneurism,  tumor,  or  large  glands  upon  the 
trachea,  bronchi,  or  recurrent  laryngeal  nerve.  (3)  Asthma. 
(4)  Diseases  of  the  lungs,  as  pneumonia,  emphysema,  cedema, 
phthisis,  abscess,  and  gaugrene.  (5)  Pleural  effusions.  (6) 
Cardiac  disease.  (7)  Paralysis  of  the  muscles  of  respira- 
tion.    (8)  Abdominal  distention.     (9)  Anaemia. 


174  DISEASES  OF  THE   RESPIRATORY  SYSTEM. 

The  number  of  respirations  per  minute.    In  the  healthy 
male  adult  the  number  of  respirations  is  about  18  to  20  per 
minute.     In  women  and  children,  breathing  is  somewhat  more, 
rapid.     The  ratio  between  respirations  and  pulse-beats  is  1  to 
4  or  4.5. 

Rapid  respirations  are  noted  in  excitement ;  in  pyrexia ;  in 
inflammatory  diseases  of  the  lungs  ;  in  anaemia  ;  in  certain  affec- 
tions involving  the  base  of  the  brain;  in  poisoning  from  certain 
drugs  which  affect  the  respiratory  centre ;  in  hysteria ;  in  painful 
affections  of  the  respiratory  muscles,  as  pleurodynia,  pleurisy. 

Infrequent  respirations  are  observed  in  certain  diseases  of 
the  brain,  as  meningitis,  tumor,  apoplexy;  in  advanced  fatty 
degeneration  of  the  heart ;  in  certain  forms  of  coma,  particularly 
ursemic  and  diabetic ;  in  poisoning  with  certain  drugs,  espe- 
cially opium ;  in  obstruction  to  the  air-passages,  as  in  asthma 
and  in  laryngeal  spasm. 

Cheyne-Stokes,  or  tidal-wave  breathing.  In  this  type  the 
respirations  gradually  increase  in  rapidity  and  volume  until 
they  reach  a  climax,  then  gradually  subside  and  finally  cease 
entirely  for  from  five  to  fifty  seconds,  when  they  begin  again. 
It  depends  on  some  disturbance  of  the  respiratory  centre  the 
exact  nature  of  which  is  still  undetermined.  It  is  usually  a 
forerunner  of  death,  but  cases  have  been  reported  in  which  it 
has  lasted  several  months. 

Its  chief  causes  are :  (1)  Certain  cerebral  diseases,  as  apo- 
plexy, meningitis,  and  tumor.  (2)  Advanced  cardiac  disease, 
especially  fatty  degeneration.  (3)  Certain  forms  of  coma,  espe- 
cially that  produced  by  ureemia,  opium-poisoning,  and  sun- 
stroke. 

COUGH. 

Cough  results  from:  (1)  All  diseases  of  the  lungs  and 
bronchi.  (2)  Many  diseases  of  the  larynx.  (3)  Foreign 
bodies  in  the  air-passages.  (4)  Certain  infectious  diseases, 
most  of  which,  however,  are  associated  with  catarrh,  as  whoop- 
ing-cough, measles,  influenza.  (5)  Inhalation  of  irritating 
vapors  or  gases.  (6)  Reflex  causes,  such  as  pressure  on  the 
recurrent  laryngeal  nerve  by  an  aneurism,  and  uterine  and 
gastro-intestinal  affections.     (7)  Hysteria. 


EXPECTORATION.  175 

Laryngeal  Cough. — This  cough  has  a  hard,  metallic,  ringing 
intonation,  and  has  been  termed  "croupy".  It  is  observed  in 
laryngitis ;  in  whooping-cough  ;  in  tuberculosis  and  syphilis  of 
the  larynx ;  when  a  foreign  body  has  lodged  in  the  larynx ; 
when  an  aneurism  or  mediastinal  tumor  presses  on  the  recur- 
rent laryngeal  nerve,  and  irritates  it ;  and  in  hysteria. 

Dry  Cough. — Cough  without  expectoration  is  especially  ob- 
served in  the  beginning  of  inflammatory  diseases  of  the  bronchi 
and  lungs  ;  in  pleurisy  ;  in  most  chest  diseases  of  early  child- 
hood ;  and  from  reflex  irritation. 

Moist,  or  loose  cough  occurs  in  bronchitis,  bronchiectasis, 
convalescent  pneumonia,  and  phthisis. 

EXPECTORATIOIV. 

Mucoid  sputum  is  noted  especially  in  the  beginning  of  acute 
bronchitis;  in  asthma;  in  the  early  stage  of  pneumonia  ;  and 
in  pulmonary  oedema.     In  the  last  it  is  very  frothy  and  watery. 

MuGo-purulent  Sputum. — This  is  observed  in  subacute  and 
chronic  catarrhal  affections  of  the  lungs  and  bronchi,  espe- 
cially in  chronic  bronchitis,  convalescent  pneumonia,  and 
phthisis. 

Purulent  Sputum. — Sputum  is  rarely  composed  of  pure  pus. 
Expectoration  almost  entirely  purulent  is  observed  in  bron- 
chiectasis, in  phthisis  with  cavities,  in  abscess  of  the  lung, 
and  when  an  empyema  ruptures  into  the  lung. 

Prune-juice  Sputum. — Expectoration  tinged  with  altered 
blood  so  as  to  resemble  prune-juice.  It  results  from  reten- 
tion of  the  blood  in  the  lung,  and  is  observed  in  advanced 
croupous  pneumonia,  especially  low  forms,  in  gangrene  of  the 
lung,  and  in  cancer  in  the  lung. 

Rusty  Sputum. — A  rusty  and  tenacious  sputum  is  strongly 
indicative  of  croupous  pneumonia. 

Sputum  containing  fibrous  shreds  is  observed  in  membra- 
nous croup,  in  diphtheria,  and  in  fibrinous  bronchitis. 

Currant-jelly  sputum  is  indicative  of  cancer  in  the  lungs. 

Fetid  sputum  usually  results  from  bronchiectasis,  advanced 
phthisis  with  cavities,  gangrene  of  the  lung,  and  abscess  of 
the  lung. 


17  (J  DISEASES   OF   THE  RESPIRATORY  SYSTEM. 

Such  sputum  when  allowed  to  stand  in  a  conical  glass  set- 
tles in  three  layers :  an  upper  layer  of  dirty  froth,  a  middle 
layer  of  turbid  mucus  in  which  are  suspended  purulent  strings, 
and  a  bottom  layer  of  decomposed  pus. 

Nummular  Sjmtum. — Sputum  found  in  round,  flat,  coin- 
shaped  masses,  which  are  heavy  aud  sink  in  water.  This 
sputum  is  observed  in  advanced  phthisis,  in  chronic  bron- 
chitis, and  in  bronchiectasis. 


THE  MICROSCOPY  OF  SPUTUM. 

Elastic  fibres  are  found  in  the  sputum  in  phthisis,  abscess, 
gangrene  of  the  lungs,  aud  in  some  cases  of  bronchiectasis. 

Fig.  10. 


Elastic  Fibres. 

The  Detection  of  JElastie  Fibres. — Place  the  sputum  Avhich 
has  collected  during  the  night  in  a  glass  beaker,  aud  add  to  it 
an  equal  volume  of  a  solution  of  caustic  soda  (20  .grains  to 
the  ounce),  and  boil  over  a  spirit-lamp,  stirring  it  occasionally 
with  a  glass  rod.  As  soon  as  it  boils  pour  into  a  conical  glass, 
and  add  four  or  five  times  the  amount  of  cold  distilled  water. 
Allow  the  mixture  to  stand  for  two  to  three  hours,  and  exam- 
ine the  sediment  as  for  tube-casts.     (Fenwick.) 

Spirals  of  Mucin. — Tightly-coiled  spirals  of  mucin,  which 
probably  represent  moulds  of  the  fine  bronchioles,  were  first 
pointed  out  by  Curschmann  in  the  sputum  of  asthma.  They 
have  also  been  observed  in  the  sputum  of  croupous  pneumonia. 


THE   MICROSCOPY   OF   SPUTUM. 


177 


Charcot-Leyden'S  Crystals. — These  are  small  transparent 
octahedral  crystals,  similar  to  those  found  in  the  blood  of  leu- 
caemia. They  are  observed  especially  in  the  sputum  of  asthma. 
They  have  also  been  noted  in  phthisis,  in  fibrinous  bron- 
chitis, and  in  acute  bronchitis. 


Fig.  11. 


Charcot-Leyden's  Asthma  Crystals.     (After  Eiegel.) 


Crystals  of  Fatty  Acids. — These  occur  as  fine  needles, 
singly  or  in  bundles,  and  are  often  sharply  curved  near  their 
extremities.  They  are  observed  in  the  sputum  of  chronic 
bronchitis,  of  abscess,  and  of  gangrene  of  the  lungs. 

Crystals  of  Hsematoidin. — These  occur  as  small  yellow 
needles,  rhombic  plates  or  tufts,  and  are  found  in  sputa  which 
contain  altered  blood.  They  may  be  observed  in  abscess, 
gangrene,  and  cancer  of  the  lungs. 

Tubercle  Bacilli. — The  presence  of  tubercle  bacilli  in  the 
sputum  is  an  absolute  proof  of  tuberculosis,  but  a  failure  to 
detect  them  after  one  or  two  examinations  is  no  proof  against 
12 


178  DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

phthisis.  The  bacillus  is  a  fine  rod,  in  length  about  half  the 
diameter  of  a  red-blood  corpuscle^  and  often  slightly  bent  and 
beaded.  Its  detection  depends  on  its  power,  when  stained,  of 
resisting  the  bleaching  effect  of  acids.  To  view  it  successfully, 
a  ^^2^  oil  immersion  lens  is  required. 

Fig.  12. 


Needles  of  Fatty  Acids.    (After  Striimpell.) 

GahheWs  Method. — Select  with  a  clean  needle  one  of  the 
minute  caseous  masses  contained  in  tuberculous  sputum,  spread 
it  out  in  a  very  thin  film  on  a  cover-glass,  dry  in  the  air,  and 
coagulate  the  albumin  in  the  bacteria  by  passing  the  cover- 
glass,  smeared  side  up,  three  times  through  the  flame.  Cover 
the  specimen  with  Ziehl's  carbol-fuchsin  solution  (fuchsin  1, 
alcohol  10,  5  per  cent,  aqueous  solution  of  carbolic-acid  crys- 
tals 90),  and  hold  the  cover-glass  over  the  flame  for  a  few 
minutes  at  such  a  distance  that  steam  is  formed.  Wash  off 
the  excess  of  stain  in  water,  and  counterstain  by  treating  the 
preparation  for  30  seconds  with  Gabbett's  solution  (methyl- 
blue  2,  sulphuric  acid  25,  water  75).  Again  wash  in  water, 
dry,  and  mount  in  Canada  balsam.  The  tubercle  bacilli  will 
appear  as  red  rods  in  a  blue  field. 


PHYSICAL   EXAMINATION   OF    RESPIRATOEY   ORGANS.       179 

PHYSICAL.  EXAMINATION  OF  THE 
RESPIRATORY  ORGANS. 

Inspection. 

Inspection  determines  the  shape  of  the  chest,  any  unnatural 
prominence  or  depression,  the  amount  of  expansion,  and  any 
inequality  of  expansion. 

FiK.  13. 


An  Outline  of  the  Normal  Chest. 


•  Phthisinoid  Chest. — The  antero-posterior  diameter  is  short ; 
the  thorax  is  long  and  flat ;  the  ribs  are  oblique ;  the  scapulse 
are  prominent ;  the  spaces  above  and  below  the  clavicles  are 
depressed  ;  and  tiie  angle  formed  by  the  divergence  of  the  cos- 
tal margins  from  the  sternum  is  very  acute. 

Rachitic  Chest. — This  may  resemble  the  former,  but  usually 
the  sides  are  considerably  flattened,  and  the  sternum  promi- 
nent, so  that  the  term  pigeon-breast  has  been  applied  to  this 
particular  form.  The  sternal  ends  of  tlie  ribs  are  enlarged  or 
"  beaded,"  and  this  characteristic  has  given  rise  to  the  term 
"  rachitic  rosary."  There  is  often  a  circular  constriction  of 
the  thorax  at  the  level  of  the  xiphoid  cartilage. 

Emphysematous    Chest In    advanced    emphysema    the 

thorax  is  short  and  round ;  the  antero-posterior  diameter  is 
often  as  long  as  the  transverse  diameter  ;  the  ribs  are  horizon- 
tal ;  the  angle  formed  by  the  divergence  of  the  costal  margin 


I 


180  DISEASES   OF   THE   RESPIRATORY    SYSTEM. 

Fig.  14. 


Eacliitie  Chest. 


from  the  sternum  is  very  obtuse  or  quite  obliterated.     The 
term  "'  barrel-shaped  chest"  is  applied  to  this  configuration. 

Fig.  15. 


Emphysematous  Chest. 

Local  Prominences  and  Depressions. — An  unnatural  promi- 
nence or  depression  is  often  observed  over  the  lower  part  of 
the  sternum,  and  is  generally  congenital.  The  term  funnel- 
breast  or  shoeraaker's-breast  (because  it  may  result  from  the 
pressure  of  tools)  has  been  applied  to  the  sternal  depression. 

A  Unilatei^al  or  Local  Depression  may  be  due  to:  (1) 
Phthisical  consolidation.  (2)  Cavity.  (3)  Pleurisy  with 
fibrous  adhesions. 

A  Unilateral  or  Local  Prominence  may  be  due  to:  (1) 
Pleurisy   with    eftusion.      (2)    Pneumothorax,   hydrothorax, 


PHYSICAL    EXAMINATION    OF    EESPIEATORY   ORGANS.       181 

hsemothorax.  (3)  An  aneurism  or  tumor.  (4)  Compensatory 
emphysema,  resulting  from  impairment  of  the  opposite  lung. 
(5)  Cardiac  enlargements  (left  side).  (6)  Enlargements  of 
the  abdominal  organs,  especially  the  liver  and  spleen. 

Expansion. — In  women  and  in  children,  breathing  is  largely 
thoracic,  or  costal ;  in  men  and  in  the  old  of  both  sexes,  it  is 
largely  abdominal,  or  diaphragtnatic. 

Restricted  abdominal  breathing  is  observed  in  pregnancy,  in 
abdominal  tumors  and  effusions  ;  in  peritonitis  ;  in  diaphrag- 
matic pleurisy  ;  in  paralysis  of  the  phrenic  nerve  from  pressure 
or  from  bulbar  disease ;  and  occasionally  in  the  "  hysterical 
abdomen." 

Palpation. 

Palpation  serves  to  detect  any  thoracic  tenderness,  oedema, 
friction-fremitus,  or  rSles,  and  to  determine  the  vocal  fremitus 
and  amount  of  expansion. 

Thoracic  tenderness  is  observed  in  pleurisy ;  in  phthisis 
and  pneumonia  from  being  associated  witli  pleurisy  ;  in  pleuro- 
dynia ;  in  intercostal  neuralgia  (confined  to  cei'tain  spots); 
aud  in  surgical  affections,  like  caries  and  fracture  of  the  ribs ; 
and  in  contusion  and  inflammation  of  the  parietes. 

(Edema  of  the  chest  walls  is  recognized  by  "■  pitting"  when 
pressure  is  made  with  the  finger.  It  may  be  observed  in  em- 
pyema ;  in  deep-seated  abscesses  of  the  parietes ;  after  the 
application  of  a  blister;  and  in  general  dropsy. 

Friction-fremitus  and  Rales. — The  friction-rub  of  pleu- 
risy and  harsh,  sonorous  rales  can  sometimes  be  detected  by 
palpation. 

Vocal,  or  Tactile  Fremitus. — The  transmission  of  the 
vibrations  of  the  voice  to  the  hand. 

In  determining  the  vocal  fremitus  observe  the  following 
precautions :  Palpate  symmetrical  parts  of  the  chest ;  make 
firm  pressure  ;  when  comparing  use  the  same  pressure  on  the 
two  sides ;  apply  the  hands  as  nearly  parallel  to  the  ribs  as 
possible  ;  ancl  remember  that  the  fremitus  is  normally  stronger 
over  the  right  apex. 


182  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

Vocal  fremitus  is  increased  in:  (1)  Phthisical  consolidation; 
(2)  Pneumonic  consolidation  ;  and  (3)  Certain  cavities. 

Vocal  fremitus  is  decreased  in:  (1)  Pleural  effusions — air, 
pus,  serum,  lymph,  or  blood.  (2)  Emphysema.  (3)  Pulmo- 
nary collapse  from  an  obstructed  bronchus.  (4)  Pulmonary 
oedema.     (5)  Morbid  growths  of  the  lung. 

Percussion. 

Percussion  determines  resonance,  pitch,  and  resistance. 

Immediate  percussion  is  performed  by  striking  the  chest  di- 
rectly with  the  fingers.  It  is  not  often  employed,  except  over 
the  clavicles,  where  the  bones  themselves  act  as  pleximeters. 

Mediate  "percussion  is  performed  by  using  the  fingers  of  one 
hand  as  a  plessor,  and  those  of  the  opposite  hand  as  a  plexi- 
meter  ;  or  by  using  a  piece  of  ivory,  glass,  or  hard  rubber  as  a 
pleximeter,  and  a  small  hammer  as  a  plessor. 

The  use  of  the  fingers  alone  is  preferable,  for  only  in  this 
way  can  resistance  be  determined. 

In  percussion  the  following  precautions  should  be  observed  : 
Place  the  finger  which  is  being  used  as  a  pleximeter  firmly 
against  the  chest,  and  preferably  parallel  to  the  ribs ;  make 
the  finger  which  is  used  as  plessor  strike  the  one  on  the  chest 
perpendicularly  ;  fix  the  forearm,  and  use  no  more  force  than 
can  be  obtained  from  a  gentle  swing  of  the  wrist.  When  pos- 
sible, percuss  all  parts  of  the  chest  anteriorly  and  posteriorly ; 
percuss  both  in  inspiration  and  in  expiration.  In  comparing 
the  two  sides,  be  sure  to  percuss  symmetrical  parts. 

Normal  Resonance. — On  the  right  side,  pulmonary  resonance 
extends  from  a  half  inch  to  an  inch  above  the  clavicle,  down- 
ward to  the  upper  border  of  the  sixth  rib  in  front,  and  to  a  line 
drawn  through  the  tenth  spinous  process  posteriorly. 

On  the  left  side,  pulmonary  resonance  extends  from  a  half 
inch  to  an  inch  above  the  clavicle,  downward,  within  the  mam- 
mary line  to  the  third  rib,  outside  of  the  mammary  line  to  the 
tenth  rib,  and  posteriorly  to  a  line  drawn  through  the  tenth 
spinous  process. 

H3^er-resonance  is  observed  in  the  following  conditions : 
(1)  Pneumothorax.  (2)  Cavities — tuberculous  or  bronchiec- 
tatic.     (3)  Emphysema.     (4)  Lowered  pulmonary  tension  in 


AUSCULTATION.  183 

the  initial  stage  of  pneumonia  and  above  a  pleural  eflPusion 
(Skoda's  resonance).  (5)  Flatulent  distention  of  the  stomach 
or  colon  (frequently  observed  over  the  left  base). 

A  tympanitic  note  is  a  hollow,  drum-like  sound  like  that 
which  is  normally  obtained  by  percussing  the  larynx  or  empty 
stomach.  The  above  conditions  are  also  capable  of  producing 
tympany. 

The  cracked-pot  sound,  or  bruit  de  pot  fele,  is  a  modified 
tympany,  and  can  be  simulated  by  percussing  over  the  cheek 
when  the  mouth  is  partially  open.     It  may  be  normally  heard  . 
over  the  chest  of  a  crying  infant  (Walshe).     In  the  adult  it  ( 
usually  indicates  a  cavity   which  has  a  free  communication  \ 
with  a  bronchus.     It  is  best  detected  by  keeping  the  ear  near 
tlie  open  mouth  of  the  patient  while  percussing. 

Dulness  or  flatness  is  recognized  in  the  following  condi- 
tions :  (1)  Phthisical  consolidation.  (2)  Pneumonic  consoli- 
dation. (3)  Pleural  effusions  of  all  kinds,  except  air.  (4)  Col- 
lapse of  the  lung.  (5)  Congestion  and  oedema  of  the  lung. 
(6)  Enlargement  of  the  liver  or  spleen  (at  the  bases).  (7) 
Morbid  growths  in  the  lung. 

Fitch. — Pitch  depends  largely  upon  the  volume  of  air,  upon 
the  tension  of  the  walls  of  the  cavity,  and  upon  the  size  of  the 
opening  which  communicates  with  the  cavity.  The  less  the  air, 
the  greater  the  tension,  and  the  smaller  the  opening,  tlie  higher 
will  be  the  pitch  of  the  note.  It  is  obvious,  therefore,  that 
conditions  which  are  associated  with  hyper-resonance  may 
yield  either  a  high-  or  a  low-pitched  note.  In  beginning 
phthisical  consolidation,  the  note  over  the  affected  apex  is 
higher  pitched ;  but  it  must  be  borne  in  mind  that  normally 
the  note  over  the  right  apex  is  higher  pitched  than  that  over 
the  left. 

Resistance. — The  greater  the  dulness  the  greater  will  be  the 
resistance  ;  hence  there  is  always  more  resistance  over  a  large 
pleural  effusion  than  ov^er  a  pneumonic  or  phthisical  con- 
solidation. 

Auscultation. 

Auscultation  determines  the  character  of  the  breathing  and 
of  the  vocal  resonance,  and  detects  adventitious  sounds,  like  rsiles. 


184  DISEASES    OF   THE   RESPIRATORY   SYSTEM. 

In  immediate  auscultation  the  ear  is  j)laced  directly  over  the 
chest,  a  soft  towel  only  intervening. 

In  mediate  auscultation  tlie  sounds  are  transmitted  through 
a  stethoscoiDe,  which  should  be  applied  to  the  bare  chest. 

In  auscultation  observe  the  following  precautions  :  Do  not 
exert  much  pressure  with  the  stethoscope ;  when  the  chest  is 
covered  with  hair  moisten  the  latter,  otherwise  it  will  produce 
friction-sounds  resembling  rales.  When  possible,  auscult  all 
over  the  chest,  anteriorly  and  posteriorly ;  auscult  on  quiet 
breathing,  on  full  inspiration,  on  full  expiration,  and  after 
coughing.  In  comparing  the  two  sides  auscult  symmetrical 
parts. 

Normal  Respiration. — Vesicular  breathing  is  heard  over  the 
body  of  the  lungs,  and  is  characterized  by  a  soft,  breezy  inspi- 
ration and  a  short,  low-pitched  expiration.  Normally,  expi- 
ration is  not  more  than  one-third  as  long  as  inspiration.  Aus- 
cultation over  the  trachea,  or  over  the  main  bronchi  in  the 
interscapular  space,  yields  bronchial  breathing,  i.  e.,  harsh 
breathing  with  prolonged  high-pitched  expiration. 

Modifications  of  the  respiratory  murmur.  Puerile  Breath- 
ing.— This  type  is  heard  normally  over  the  lungs  of  children  ; 
it  is  loud,  and  expiration  is  higher  pitched  than  in  vesicular 
breathing,  and  almost  as  long  as  inspiration. 

Exaggerated  Breathing. — This  type  has  almost  the  same 
peculiarities  as  puerile  breathing,  and  is  heard  over  a  lung 
that  is  doing  extra  work  necessitated  by  some  impairment  of 
its  fellow. 

Bronchial  or  Tubular  Breathing. — Harsh  breathing,  with 
a  prolonged  high-pitched  expiration,  which  has  sometimes  a 
tubular  quality.  Bronchial  breathing  is  heard  over :  (1) 
Phthisical  consolidation.  (2)  Pneumonic  consolidation.  (3) 
Lung  which  is  compressed.  (4)  Rarely  over  a  lung  which  is 
infiltrated  with  a  morbid  growth. 

Amphoric  and  Cavernous  Breathing. — These  two  are  almost 
identical;  the  sounds  are  loud,  and  expiration  is  prolonged  and 
hollow.  The  pitch  of  amphoric  breathing  is  a  little  higher 
than  that  of  cavernous.  Amphoric  breathing  may  be  imitated 
by  blowing  over  the  mouth  of  an  empty  jar. 

Amphoric  or  cavernous  breathing  may  be  heard  in  the  fol- 


AUSCULTATION.  185 

lowing  conditions :    (1)  Phthisical  or  bronchiectatic  cavities. 

(2)  Pneumothorax,  when  the  opening  in  the  lung  is  patulous. 

(3)  Areas  of  consolidation  near  a  large  l)ronchus.     (4)  Some- 
times over  lung  compressed  by  a  moderate  effusion. 

Asthmatic  Breathing. — Harsh  breathing  with  a  prolonged 
wheezing  expiration.  It  may  resemble  bronchial  breathing, 
but,  unlike  the  latter,  it  is  heard  all  over  the  chest. 

The  Breathing  of  Emphysema. — Weak  breathing,  with  pro- 
longed low-pitched  or  inaudible  expiration. 

Cogged-ioheel,  or  Jerky  Breathing. — The  respiratory  murmur 
is  not  continuous,  but  is  broken  into  waves.  It  is  not  indicative 
of  any  special  disease,  but  it  is  frequently  observed  in  bron- 
chitis and  in  incipient  phthisis. 

Weak  or  Shallow  Breathing. — This  is  noted  :  (1)  When  the 
chest-walls  are  thick.  (2)  In  the  old  and  feeble.  (3)  In 
emphysema.  (4)  In  pleural  effusion.  (5)  In  incipient 
phthisis.  (6)  In  painful  affections  of  the  chest,  like  pleuro- 
dynia and  beginning  pleurisy.     (7)  In  pulmonary  cedema. 

Vocal  Resonance. — The  vibrations  of  the  voice  transmitted 
to  the  ear. 

Vocal  resonance  is  normally  more  marked  over  the  right 
apex.  It  is  abnormally  increased  in:  (1)  Pneumonic  consoli- 
dation. (2)  Phthisical  consolidation.  (3)  Cavities  which  freely 
communicate  with  a  bronchus. 

Vocal  resonance  is  diminished  or  absent  in:  (1)  Pleural 
effusions — air,  pus,  serum,  lymph,  or  blood.  (2)  Emphysema. 
(3)  Pulmonary  collapse.     (4)  Pulmonary  oedema. 

Bronchophony. — Extreme  exaggeration  of  the  vocal  resonance ; 
the  sounds,  but  not  the  words,  are  transmitted.  It  is  especially 
noted  over  marked  consolidations  and  over  certain  cavities. 

Pectoriloquy. — The  distinct  transmission  of  articulate  speech 
to  the  ear;  the  words  appear  to  emanate  from  the  spot  which 
is  ausculted. 

Pectoriloquy  is  heard  over  :  (1)  Cavities  which  communicate 
with  a  bronchus.  (2)  Areas  of  consolidation  in  the  neighbor- 
hood of  a  large  bronchus.  (3)  Pneumothorax,  when  the  open- 
ing in  the  lung  is  patulous.     (4)  Some  pleural  effusions. 

JEgophony. — A  modified  bronchophony,  characterized  by  a 
trembling,  bleating  sound.     It   is  usually  heard   over  slight 


186  DISEASES   OP   THE   RESPIRATORY  SYSTEM. 

pleural  effusions  near  the  upper  border  of  dulness,  especially 
near  the  inferior  angle  of  the  scapula. 

It  is  occasionally  heard  in  beginning  pneumonia. 

Adventitious  Sounds.  Redes,  or  Rhonchi. — These  are  abnor- 
mal sounds  which  replace  or  accompany  the  respiratory  murmur. 

C  Vesicular  ^  Crepitant. 

j 

Pulmonary  rales    \  ^^         (Sonorous. 

■r,         1  •  1  I  I  Sibilant. 

Bronchial  J  Vc-   i,        -i.     i. 

J.  j  I  Dubcrepitant. 

'-Moist     \  Bubbling. 

(Gurgling. 

Extra-pulmonary  rales  =  Pleuritic  friction-sounds. 

Crefpitant  Redes. — These  are  very  fine  rales,  and  are  heard  at 
the  end  of  inspiration.  They  may  be  simulated  by  rubbing  a 
lock  of  hair  between  the  fingers.  They  have  been  especially 
associated  with  the  first  stage  of  croupous  pneumonia,  and  it 
has  been  supposed  that  they  were  due  to  the  forcible  separation 
of  adherent  vesicular  walls.  Rales  very  similar  to,  if  not  iden- 
tical with  these,  are  heard  in  capillary  bronchitis  and  in  pul- 
monary oedema. 

Dry  rales  are  probably  produced  by  the  presence  of  viscid 
secretion  in  the  tubes ;  they  have  a  more  or  less  whistling, 
musical,  or  squeaking  intonation.  They  are  heard  particularly 
in  bronchitis  and  asthma.  Sibilant  rales  are  whistling  and 
high  pitched  ;  sonorous  rales  have  a  humming  quality  and  are 
lower  pitched.  Dry  rales  may  be  heard  on  inspiration,  expi- 
ration, or  both. 

Moist  rales  result  from  the  presence  of  liquid  in  the  tubes  ; 
the  thinner  the  liquid  and  the  larger  the  tube,  the  coarser  will 
be  the  rales.  They  may  be  heard  on  inspiration,  expiration, 
or  both. 

Subcrepitant,  or  crackling  rdles  are  fine  moist  rales,  and  heard 
in  all  conditions  which  are  associated  with  liquid  in  the  smaller 
tubes,  as  bronchitis,  capillary  bronchitis,  pulmonary  oedema, 
and  beginning  phthisis. 

Rubbling  redes  are  coarser  than  subcrepitant ;  and  are  heard 
in  bronchitis,  in  resolving  croupous  pneumonia,  over  phthisical 
deposits  which  are  softening,  and  over  small  cavities. 


AUSCULTATION.  187 

Gurgling  rdles  are  very  coarse  and  resemble  the  bursting  of 
large  bubbles.  They  are  heard  over  large  cavities  which  con- 
tain fluid,  and  in  the  trachea  in  the  so-called  "  death-rattle." 

Frietion-sounds  are  prorlaced  by  the  rubbing  together  of 
roughened  pleural  surfaces.  They  may  be  heard  both  in  in- 
spiration and  expiration,  and  often  resemble  subcrepitant  rales, 
but  they  are  more  superficial  and  localized  than  the  latter,  and 
are  not  modified  by.  cough  or  deep  inspiration. 

A  roughened  pleura  in  the  neigliborhood  of  the  heart  may 
produce  a  friction-sound  of  cardiac  rhythm,  and  one  which 
will  still  continue  when  the  breath  is  held ;  under  other  condi- 
tions pleural  friction-sounds  cease  when  respiration  is  sus- 
pended. 

Metallic  Tinkling. — This  name  is  applied  to  silvery  or  bell- 
like sounds  which  are  heard  at  intervals  over  a  pneumo- 
hydrothorax  or  large  cavity.  Speaking,  coughing,  and  deep 
breathing  usually  induce  them.  Care  must  be  taken  not  to 
confound  them  with  similar  sounds  produced  by  the  presence 
of  liquid  in  a  distended  stomach. 

SucGussion-splash,  or  Hippocratio  Succussion. — This  is  a 
splashing  sound  produced  by  the  presence  of  air  and  liquid  in 
the  cliest.  It  may  be  elicited  by  gently  shaking  the  patient 
while  auscultating.  It  nearly  always  indicates  either  a  hydro- 
or  a  pyo-pneumothorax,  although  it  has  been  detected  over 
very  large  cavities. 

Air  and  liquid  in  the  stomach  produce  a  similar  sound. 

Mensuration. 

In  measuring  the  sides  of  the  chest  observe  the  following 
precautions  :  Measure  from  the  middle  of  the  sternum  to  the 
spinous  processes ;  measure  both  sides  after  inspiration  and 
after  expiration  ;  apply  the  tape  with  equal  firmness  to  the  two 
sides.  In  comparing,  measure  corresponding  levels,  and  re- 
member that  the  right  side  is  from  half  an  inch  to  an  inch 
greater  in  circumference  than  the  left. 

The  conditions  which  render  one  side  more  prominent  than 
the  other  have  already  been  considered. 


188  DISEASES   OF  THE   RESPIRATORY  SYSTEM. 


CORYZA. 

(Acute  Rhinitis,  Cold  in  the  Head.) 

Definition. — An  acute  inflammation  of  the  nasal  cavities. 

Etiology. — Exposure  to  cold  drafts  and  to  wet,  especially 
when  the  body  is  overheated,  is  a  common  cause.  It  may  be 
excited  by  the  inhalation  of  irritating  vapors  or  dust.  It  is 
an  expression  of  iodism.  It  is  a  symptom  of  certain  infectious 
diseases — especially  syphilis,  measles,  and  influenza. 

Pathology. — The  mucous  membrane  is  red  and  swollen. 
In  the  first  stage  there  is  no  secretion,  but  later  irritating, 
watery  mucus  flows  from  the  nose  and  excoriates  the  lip ;  this 
in  time  is  followed  by  a  copious  muco-purulent  discharge. 

Symptoms.  —  The  disease  is  ushered  in  with  chilliness, 
malaise,  fulness  iu  the  head,  and  sneezing.  The  nasal  cham- 
bers are  obstructed,  so  that  the  patient  is  obliged  to  breathe 
through  his  mouth.  At  first  there  is  no  secretion,  but  in 
twenty-four  or  forty-eight  hours  a  watery  discharge  is  estab- 
lished, which  later  becomes  muco-purulent.  Slight  fever  and 
its  associated  symptoms  are  commonly  present.  The  duration 
is  from  a  few  days  to  two  we'eks. 

Complications. — The  disease  is  often  accompanied  with 
conjunctivitis,  pharyngitis,  laryngitis,  and  catarrh  of  the 
Eustachian  tube  and  middle  ear  which  results  in  temporary 
deafness. 

Prognosis. — Favorable. 

Treatment. — In  the  early  stage  a  cold  in  the  head  can 
frequently  be  aborted  by  the  use  of  hot  drinks,  a  laxative, 
moderate  doses  of  quinine,  and  the  application  of  menthol  to 
the  nasal  chambers.  Some  crystals  of  menthol  may  be  placed 
in  a  wide-mouth  bottle,  and  their  vapor  inhaled  for  from  ten 
to  twenty  minutes  several  times  during  the  day.  A  spray  of 
menthol  may  be  employed  : — 

]^  Menthol,  3j  ; 

01.  amygd.  dulcis,  vel  benzoiual,  f^iij. — M. 
Sig. — Spray  into  the  nose  several  times  daily. 


CHRONIC  NASAL   CATARRH.  189 

Cocaine  is  often  efficient  in  allaying  the  fulness  and  distress; 
a  four  per  cent,  solution  may  be  applied  to  the  nose  on  a 
pledget  of  cotton  or  by  means  of  a  camel's-hair  brush. 

When  the  symptoms  are  severe  Dover's  powder  (gr.  v)  may 
be  given  in  combination  with  quinine  (gr.  v)  thrice  daily. 

CHRONIC  NASAL  CATARRH. 

(Chronic  Rhinitis.) 

Definition. — A  chronic  inflammation  of  the  nasal  mucous 
membrane,  characterized  by  increased  secretion  and  impair- 
ment of  the  sense  of  smell. 

Etiology. — Repeated  attacks  of  acute  coryza,  impure  air, 
the  continual  inhalation  of  irritating  dusts  or  vapors,  lowered 
vitality,  and  congenital  or  acquired  obstruction  of  the  nasal 
chambers  are  causal  factors.  It  is  also  an  expression  of 
syphilis. 

Varieties. — Two  varieties  have  been  recognized  :  Chronic 
hypertrophic  rhinitis  and  chronic  atrophic  rhinitis. 

Hypertrophic  Rhinitis.  Symptoms. — A.  thick  mucous  dis- 
charge from  the  nose ;  great  liability  to  attacks  of  acute 
coryza  ;  obstruction  of  one  or  both  nasal  cavities,  causing 
mouth-breathing ;  a  nasal  intonation  of  the  voice  ;  frontal 
headache  ;  and  impairment  of  the  sense  of  smell. 

Symptoms  of  catarrh  of  the  neighboring  organs  are  fre- 
quently present.  The  most  common  of  these  are  :  dryness  of 
the  throat  and  hawking  from  pharyngitis ;  deafness  from 
catarrh  of  the  middle  ear  ;  and  watering  of  the  eyes  from  catar- 
rhal occlusion  cf  the  lachrymal  canal. 

Inspection. — The  bridge  of  the  nose  is  frequently  flattened, 
and  the  alse  are  thickened  and  red ;  the  mucous  membrane  is 
red  and  the  cavities  are  more  or  less  occluded  from  hyper- 
trophy of  the  cavernous  tissue  covering  the  turbinated  bones. 
In  advanced  cases  exostoses  from  the  bony  framework  are 
sometimes  noted. 

Prognosis. — Under  judicious  and  persistent  treatment  the 
affection  is  curable. 

Treatment. — The  naso-pharynx  must  be  kept  clean  by 


190  DISEASES   OF   THE    RESPIRATORY   SYSTEM. 

means  of  autiseptic  douches  or  sprays ;  Dobell's  solution  (see 
page  31)  or  the  following  may  be  employed  for  this  purpose: — 

R     Sodii  boratis, 

Sodii  bicarbonatis,  aa  3ss ; 

Sodii  benzoatis, 

Sodii  salicylatis,  aa  gr.  ij  ; 

Sodii  chloridi,  gr.  vij  ; 

Eucalyptol,  thymol,  aa  gr.  j  ;  * 

Menthol,  gr.  ss ; 

Olei  gaultheriae,  gtt.  j  ; 

Glycerini,  fgss ; 

Alcoholis,  f3j ; 

Aqufe,  q.s.  ad  Oj. — M. 

Mild  astringent  sprays  are  often  useful,  and  sulphate  of 
zinc  or  sulphate  of  copper  (five  to  ten  grains  to  the  ounce)  may 
be  employed  for  this  purpose. 

Tonics  like  cod-liver  oil,  hypophosphites,  iron,  arsenic,  and 
strychnia  are  often  indicated. 

To  effect  a  cure  the  naso-pharynx  must  be  unobstructed ; 
hypertrophies  and  exostoses  must  be  removed  and  deviations 
of  the  septum  corrected  by  surgical  means. 

Atrophic  Rhinitis.  (Ozcena)  Symptoms.— A  sense  of  dry- 
ness in  the  nose  and  throat ;  a  thick  purulent  discharge,  or  the 
expulsion  of  discolored  crusts ;  an  offensive,  putrid  odor,  which 
has  given  rise  to  the  terra  ozaena ;  impairment  of  the  sense 
of  smell.  The  general  health  is  always  poor;  such  patients 
are  usually  thin  and  ausemic. 

Inspection. — The  chambers  are  large  ;  the  mucous  membrane 
is  pale,  dry,  and  glazed  ;  adherent  scabs  are  generally  present. 
In  advanced  cases,  ulceration  and  necrosis  are  observed. 

Prognosis. — Perfect  cure  is  rarely  obtainable ;  but  treat- 
ment may  effect  great  improvement. 

Treatment. — Crusts  must  be  removed  and  the  nasal 
chambers  kept  clean  with  antiseptic  sprays  or  douches.  Stim- 
ulating applications  are  useful,  and  solutions  of  nitrate  of 
silver,  sulphate  of  iron,  or  sulphate  of  zinc  may  be  employed. 
A  30  per  cent,  solution  of  lactic  acid  is  also  recommended. 
Ebsteiu  uses  tampons  soaked  in  balsam  of  Peru.  AVhen  there 
is  much  purulent  discharge  a  20  per  cent,  mixture  of  ichthyol 
in  cosmoline  is  very  efficient.  General  tonics  like  cod-liver 
oil,  hypophosphites,  iron,  arsenic,  etc.  are  indicated. 


ACUTE   CATARRHAL   LARYNGITIS.  191 


ACUTE  CATARRHAL  LARYNGITIS. 

Definition, — An  acute  catarrhal  inflammation  of  the 
larynx,  characterized  by  hoarseness,  hard  coughj  and  painful 
deglutition. 

Etiology. — Improper  use  of  the  voice  ;  exposure  to  cold 
and  wet ;  the  inhalation  of  irritating  dusts  or  vapors ;  the  im- 
paction of  foreign  bodies  are  its  common  causes.  It  is  also  an 
associated  condition  in  certain  infectious  diseases,  like  whoop- 
ing-cough, measles,  diphtheria,  and  influenza. 

Pathology. — The  mucous  membrane  is  red,  swollen,  and 
injected. 

In  grave  cases  the  tissues  may  be  markedly  (edematous. 

Symptoms. — Hoarseness  of  the  voice  or  aphonia ;  hard, 
ringing  cough ;  pain  in  the  throat  increased  by  speaking, 
coughing,  and  swallowing  ;  expectoration,  which  is  first  scanty 
and  later  muco-purulent ;  fever  and  its  associated  symptoms. 
In  sensitive  people,  and  especially  in  children,  paroxysms  of 
croupy  cough  and  dyspnoea  (false  croup)  may  result  from 
spasm  of  the  vocal  cords ;  and  when  there  is  much  oedema, 
dyspnoea  or  asphyxia  will  be  a  prominent  feature. 

Inspection. — The  mucous  membrane  of  the  laryngeal  walls 
and  vocal  cords  is  red  and  swollen.  In  grave  cases  the  tissues 
are  highly  oedematous. 

Prognosis, — In  simple  laryngitis  without  oedema  the  prog- 
nosis is  altogether  favorable.  The  attack  usually  lasts  from 
a  week  to  ten  days.  When  there  is  oedema  of  the  larynx, 
indicated  by  dyspnoea  or  asphyxia,  the  prognosis  is  grave. 

Treatment. — The  patient  should  be  confined  to  his  room 
and  preferably  to  bed.  The  temperature  of  the  room  should 
be  70°  or  75°,  and  the  atmosphere  should  be  moistened  by  the 
generation  of  steam. 

Iodine,  or  in  sev^ere  cases  an  ice-bladder,  should  be  applied 
to  the  throat.  The  inhalation  of  medicated  vapors  is  decidedly 
useful,  and  one  of  the  following  may  be  employed  :  Lime- 
water,  Dobell's  solution,  wine  of  ipecac  (diluted  with  two 
volumes  of  water),  or  the  menthol  mixture  mentioned  in  the 
treatment  of  acute  coryza. 


192  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

Internal  Treatment. — A  saline  laxative  may  be  administered 
at  the  beginning,  and  followed  by  one  of  the  following  seda- 
tive mixtures :  Dover's  powder  (gr.  v)  with  quinine  (gr.  v) 
thrice  daily,  or  : — 

^  Potassii  citratis, 

Potassii  bromid.,  aa  gij  ; 
Apomorph.  hydrochlor.,  gr.  ^\ 
Aquae  et  syr.  sarsaparillse  comp.,  aa  f  Jiss— M,    . 
Sig. — A  teaspoonful  every  two  honrs  to  a  child  of  five  years. 

Or — One  of  the  following  tablets  devised  by  Dr.  Seller  : — 

1^  Potass,  chlor., 

Potass,  bromid., 

Pulv.  ext.  glycyrrliizfe,  aa  3j  ; 

Tinct.  ferri  clilor.,  f^ss  ; 

Saccliar.,  etc.,  q.  s.— M. 
Pt.  in  trochisci  No  xx. 
Sig. — One  every  three  or  four  hours. 

CEdema  of  the  larynx,  indicated  by  extreme  dyspnoea,  will 
require  scarification  of  the  mucous  membrane  or  tracheotomy. 


CHRONIC  LARYNGITIS. 

Simple  Chronic  Catarrhal  Laryngitis.  Symptoms. — Tick- 
ling in  the  throat,  huskiness  of  the  voice,  fatigue  and  pain 
after  moderate  use  of  the  voice,  and  the  expectoration  of  viscid 
mucus  are  the  usual  symptoms. 

LaryngoscopiG  examinati&n  reveals  redness  of  the  mucous 
membrane  and  sometimes  slight  ulcerations. 

Treatment. — The  patient  must  learn  to  use  the  voice 
properly  ;  sounds  must  be  expelled  by  tlie  abdominal  mu.scles 
and  diaphragm,  and  not  by  the  muscles  of  the  throat.  Flan- 
nel protectors  should  be  avoided,  and  the  application  of  cool 
water  to  the  neck,  night  and  morning,  instituted  in  their  stead. 
Tonics  are  generally  indicated.  Expectorants  which  are  elim- 
inated by  the  respiratory  mucous  membrane  are  useful ;  and 
one  of  the  following  may  be  employed  :  Terebene  (gtt.  v  on 
sugar),  oleoresin  of  cubebs  (gtt.  x-xx  on  sugar),  oil  of  euca- 
lyptus (gtt.  V  in  capsule). 


CHRONIC   LARYNGITIS.  193 

Topical  Treatment. — A  faradic  current  to  the  neck  is  often 
beneficial;  medicated  solutions  should  be  applied  to  the  larynx 
by  means  of  a  brush  or  atomizer.  The  following  are  the 
remedies  commonly  employed  :  Nitrate  of  silver,  chloride  of 
ammonium,  chlorate  of  potassium,  sulphate  of  zinc,  and  tinc- 
ture of  benzoin. 

Tuberculous  Laryngitis. — This  is  nearly  always  secondary 
to  pulmonary  tuberculosis,  but  it  occasionally  occurs  as  a  pri- 
mary affection. 

Symptoms. — Hoarseness  of  the  voice  or  aphonia ;  pain  in 
the  throat  increased  by  coughing,  speaking,  or  swallowing; 
and  hacking  cough  are  the  usual  symptoms. 

Laryngoscopic  Examinaiion. — The  mucous  membrane  is 
pale  and  thickened ;  the  arytenoid  cartilages  are  considerably 
swollen  ;  small,  irregular,  shallow  ulcers  with  gray  bases  are 
frequently  noted,  particularly  in  the  inter-arytenoid  space. 

Treatment. — Remedies  must  be  directed  to  the  primary 
pulmonary  disease.  Local  applications  are  required  to  relieve 
the  pain.  Powders  of  iodoform  or  morphine  may  be  dusted  on 
the  ulcers,  or  a  solution  of  nitrate  of  silver,  of  cocaine,  or  of 
menthol  may  be  applied  by  means  of  a  laryngeal  brush. 

Syphilitic  laryngitis  may  manifest  itself  in  catarrhal  in- 
flammation, or  mucous  patches,  but  the  most  common  expres- 
sion is  a  gummatous  infiltration,  which  breaks  down,  ulcerates 
the  cartilages,  and  ultimately  leads  to  cicatrization  and  de- 
formity. 

Symptoms. — Hoarseness  of  the  voice,  hacking  cough,  and 
some  difficulty  in  deglutition.  Subjective  symptoms  are  often 
absent,  though  examination  may  reveal  extensive  lesions. 

Laryngoscopie  Examination. — Deep  ulcers  with  raised  edges, 
often  symmetrically  arranged.  Necrosis  of  the  cartilages  re- 
sults in  advanced  cases. 

Diagnosis. — The  history,  the  presence  of  other  syphilitic 
lesions,  the  deep  symmetrical  ulcers,  the  effect  of  treatment, 
and  the  absence  of  marked  pain  and  of  pulmonary  lesions  will 
serve  to  distinguish  it  from  tuberculous  laryngitis. 

Treatment. — The  system  should  be  rapidly  brought  under 
the  influence  of  antisyphilitic  remedies  ;  for  this  purpose  mer- 
13 


194  DISEASES    OF   THE    RESPIRATORY    SYSTEM. 

curial  inunctions  may  be  employed,  and  iodides  and  mercurials 
given  internally  : — 

^  Hydrarg.  chlor.  corros.,  gr.  j  ; 
Potass,  iodidi,  3ij-3iv  ; 
Syr.  sarsapai-illee  comp.,  fgjss  ; 
Aquee,  q.  s.  ad  f.^iij. — M. 
Sig. — A  teaspoonful  twice  daily  after  meals. 

Local  applications,  carefully  applied  by  the  aid  of  the  laryn- 
goscopic  mirror,  are  also  required.  Iodoform,  or  acid  nitrate 
of  mercury  (1  to  5  of  water),  may  be  selected  for  this  purpose. 

When  the  laryngeal  movements  interfere  with  healing, 
tracheotomy  should  be  performed.  The  same  operation  or 
mechanical  dilatation  is  sometimes  required  for  the  resulting 
cicatricial  stenosis. 

SPASMODIC  CROUP. 

(False  Croup.) 

Definition. — Spasm  of  the  vocal  cords,  excited  by  catarrh 
of  the  larynx. 

Etiology. — The  attacks  usually  occur  in  young  children, 
and  are  induced  by  the  causes  of  catarrhal  laryngitis. 

Sympto:ms. — Generally  there  has  been  a  little  hoarseness 
and  cough  during  the  day,  and  at  night  the  child  is  awakened 
from  sleep  by  a  severe  paroxysm  of  suffocative  cough.  The 
latter  has  a  peculiar,  hard,  metallic  quality,  and  is  associated 
with  the  evidences  of  dyspnoea,  namely  :  Anxious  face,  dilating 
nostrils,  prominent  sterno-cleido-mastoids,  and  retraction  of 
the  base  of  the  chest  with  each  inspiratory  effort.  During  the 
paroxysm  the  skin  is  hot  and  the  pulse  is  tense  and  rapid.  In 
from  a  few  moments  to  an  hour  the  cough  ceases,  free  perspi- 
ration follows,  and  the  child  falls  to  sleep. 

Two  or  three  similar  attacks  may  occur  in  the  same  night, 
but  on  the  following  day  the  child  appears  quite  well.  A 
recurrence  of  the  seizures  for  several  successive  nights  is  not 
infrequent. 

Diagnosis.  Laryngismus  Stridulus. — This  is  a  pure  neu- 
rosis, and  is  often  associated  with  the  rachitic  diathesis.  The 
paroxysms  resemble  those  of  false  croup,  but  are  associated 


MEMBRANOUS    CROUP — LARYNGISMUS    STRIDULUS.       195 

with  a  peculiar  crowing  inspiration,  and  lack  catarrhal  symp- 
toms, such  as  hoarseness  and  cough. 

Prognosis. — Always  favorable. 

Treatment. — A  sponge  moistened  with  hot  water  may  be 
applied  to  the  throat,  or  the  child  may  be  placed  in  a  hot  bath. 
If  these  simple  measures  fail,  an  emetic  will  almost  invariably 
bring  relief.  Wine  of  ipecac  (5j)  or  turpeth  mineral  (gr.  iij-v) 
may  be  selected.  Subsequent  treatment  should  be  directed  to 
tlie  laryngeal  catarrh. 

MEMBRANOUS  CROUP. 

(Croupous  Laryngitis,   True  Croup,   Pseudo-membranous 
Larjrngitis.) 

See  Laryngeal  Diphtheria. 

LARYNGISMUS  STRIDULUS. 

(Spasm  of  the  Glottis,  "Child-cro-wong.") 

Definition.  —  A  paroxysmal  neurosis,  characterized  by 
spasm  of  the  adductors  of  the  larynx,  and  not  excited  by  any 
local  inflammation. 

Etiology. — Early  life  (within  the  first  two  years),  male 
sex,  and  the  rachitic  diathesis  are  the  predisposing  causes. 
The  discharge  of  motor  force  apparently  arises  in  the  medulla 
(bulbar  epilepsy),  and  may  be  excited  by  reflex  irritation,  as 
in  teething  and  gastro-intestiual  disorders.  Some  regard  it  as 
a  symptom  of  tetany. 

Symptoms. — The  attacks  often  occur  on  waking  from  sleep, 
and  are  characterized  by  a  sudden  arrest  of  breathing  and 
tonic  muscular  spasms.  The  face  is  pale,  and  later  cyanosed ; 
the  eyes  are  rolled  up ;  the  body  is  arched ;  the  thumbs  are 
turned  into  the  palms  ;  the  legs  are  extended,  and  the  soles 
turned  inward.  In  a  few  seconds  the  spasm  relaxes,  and  air 
is  drawn  through  the  glottis  with  a  shrill,  crowing  sound. 

The  seizures  vary  greatly  in  frequency ;  sevei'al  may  occur 
in  a  day,  or  they  may  be  weeks  apart. 

Diagnosis. — The  intermittent  character  of  the  affection  ; 


196  DISEASES   OF    THE    RESPIRATORY   SYSTEM. 

the  peculiar  crowing  inspiration  ;  the  absence  of  fever,  cough, 
and  hoarseness  will  serve  to  distinguish  laryngismus  from  croup. 

Prognosis. — Favorable.  In  the  very  young  death  may 
result  from  suifocation. 

Treatment.  The  Paroxysm. — Cold  water  may  be  dashed 
on  the  face  and  head,  or  a  few  drops  of  nitrite  of  amyl  or 
chloroform  may  be  placed  ou  a  handkerchief  and  held  before 
the  nose. 

The  Interval.  —  Careful  search  should  be  made  for  some 
exciting  cause ;  the  gums  may  require  lancing,  or  the  gastro- 
intestinal tract  may  demand  attention.  The  child  should  be 
placed  under  the  best  hygienic  conditions.  The  food  should 
be  plain  and  nutritious ;  tonics,  like  cod-liver  oil,  malt,  hypo- 
phosphites,  and  arsenic,  are  generally  indicated.  The  bromide 
of  potassium  is  an  efficient  antispasmodic,  and  may  be  advan- 
tageously combined  with  antipyrin  : — 

^   Antipyrin,  gr.  xxiv-xlviij  ; 
Potass,  bromid.,  ^iss-^ij  ; 
Syr.  aurant.  cort.,   f^ij  ; 
Aquse,  q.s.  ad  fgiij. — M. 
Sig. — A  teaspooaful  thrice  daily. 

(EDEMA  OF  THE  LARYNX. 

(CEdema  of  the  Glottis.) 

Definition. — An  infiltration  of  serous  fluid  into  the  sub- 
mucous tissue  of  the  larynx. 

Etiology. — It  occasionally  results  from  severe  attacks  of 
catarrhal  laryngitis.  It  may  be  induced  by  severe  inflamma- 
tion of  neighboring  organs — as  the  tonsils,  parotid  glands, 
and  pharynx.  It  may  be  a  complication  of  some  acute  infec- 
tious disease — like  diphtheria,  scarlet  fever,  or  facial  erysipelas. 
It  is  sometimes  associated  with  ulcerative  affections  of  the 
larynx,  like  tuberculosis  and  syphilis.  It  may  be  excited  by 
the  irritation  of  burns,  scalds,  or  caustics.  It  occasionally 
occurs  abruptly  in  the  course  of  Bright's  disease. 

Pathology". — The  connective  tissue  of  the  larynx  is  infil- 
trated with  a  serous  or  sero-purulent  fluid.  The  mucous  mem- 
brane is  tense  and  changed  in  color. 


BRONCHITIS,  197 

Symptoms. — Hoarseness  of  the  voice,  and  later  aphonia  ; 
extreme  dyspnoea,  at  first  on  inspiration  but  later  on  expiration 
also;  stridulous  respiration;  barking  congh ;  and  the  evi- 
dences of  dyspnoea,  namely:  Anxious  face,  protruding  eyes, 
blue  lips,  ])rominent  sterno-cleido-mastoids,  and  retraction  of 
the  base  of  the  chest.  When  the  epiglottis  is  involved  the 
swelling  can  be  detected  by  the  finger  in  the  throat. 

Laryngoscopie  Examination.  —  The  mucous  membrane  is 
swollen  and  of  a  reddish-purple  color.  The  epiglottis  may 
resemble  a  I'ound  translucent  tumor.  In  infraglottic  oedema 
the  upper  part  of  the  larynx  may  appear  normal,  but  swollen 
and  oedematous  membrane  is  seen  projecting  through  the 
glottis.     The  vocal  cords  are  rarely  affected. 

Prognosis. — Extremely  grave. 

Treatment. — When  the  symptoms  are  not  urgent,  leeches 
or  blisters  may  be  applied  over  the  larynx,  and  astringent  solu- 
tions (tannic  acid  or  alinn)  sprayed  on  the  oedematous  tissues. 
When  the  symptoms  persist,  the  parts  should  be  scarified,  and 
if  this  fails  to  relieve  the  dyspnoea,  tracheotomy  should  be 
performed. 


BRONCHITIS. 

Definition. — An  inflammation  of  the  bronchial  tubes, 
characterized  by  substernal  soreness,  cough,  muco-purulent 
expectoration,  and  dry  and  moist  rales. 

Varieties. — (1)  Acute  catarrhal  bronchitis.  (2)  Chronic 
catarrhal  bronchitis.     (3)  Fibrinous  bronchitis. 


Acute  Catarrhal  Bronchitis 

Etiology. — A  cold,  damp  climate ;  changeable  weather ; 
occupations  which  necessitate  confinement,  or  the  inhalation  of 
irritating  dusts  or  vapors  ;  debility  ;  the  gouty  diathesis  ;  and 
chronic  heart  disease  are  general  predisposing  factors. 

Exposure  to  cold  and  wet,  particularly  ^\dien  the  body  is 
overheated,  or  the  inhalation  of  irritating  gases  or  dusts  is  the 


198  DISEASES   OF   THE   RESPIRATORY   SYSTEM, 

usual  exciting  cause.  Acute  bronchitis  is  also  an  associated 
condition  in  certain  infectious  diseases,  especially  measles, 
whooping-cough,  typhoid  fever,  and  influenza. 

Pathology. — In  most  cases  the  trachea  and  large  tubes 
only  are  affected.  The  mucous  membrane  is  red,  swollen,  in- 
jected, and  more  or  less  covered  with  tenacious  muco-pus. 

Microscopic  examination  reveals  desquamation  of  epithe- 
lium and  infiltration  of  the  submucous  tissues  with  leucocytes. 

Symptoms. — Chilliness;  malaise;  a  sense  of  soreness  and 
constriction  behind  the  sternum,  which  is  increased  by  cough- 
ing ;  slight  fever  (100°-102°)  with  its  associated  symptoms ; 
cough  at  first  dry  and  painful,  but  later  accompanied  by 
muco-purulent  expectoration  which  becomes  quite  free  as  the 
inflammation  subsides. 

Physical  Signs. — Inspection,  palpation,  and  percussion 
usually  give  negative  results. 

Auscultation  at  first  reveals  sibilant  and  sonorous  rales  on 
both  sides  of  the  chest,  and  in  the  second  stage,  when  secretion 
is  established,  moist  rales. 

Diagnosis.  Influenza — High  fever,  intense  pain  in  the 
head,  back,  and  limbs,  and  great  prostration  will  serve  to  dis- 
tinguish influenza  from  bronchitis  when  the  former  is  prevalent. 

Catarrhal  Pneumonia. — Moderately  high  and  irregular 
fever,  prostration,  dyspnoea,  and  physical  signs  indicating 
consolidation  will  serve  in  the  recognition  of  pneumonia. 

Prognosis. — Favorable.  In  the  old,  young,  and  feeble 
there  is  danger  of  its  leading  to  capillary  bronchitis  or  catar- 
rhal pneumonia. 

Treatment. — The  abortive  treatment  consists  in  the  use 
of  hot  foot-baths,  a  mustard  plaster  to  the  chest,  the  internal 
administration  of  hot  drinks,  and  a  full  dose  of  Dover's  pow- 
der (gr.  x)  with  which  quinine  may  be  advantageously  com- 
bined. This  method  is  only  applicable  in  the  initial  stage,  and 
to  those  patients  who  are  willing  to  remain  indoors  for  the  fol- 
lowing twenty-four  hours. 

The  young,  old,  and  enfeebled  should  be  confined  to  bed. 
A  turpentine  stupe,  mustard  plaster,  or  iodine  may  be  applied 
to  the  chest. 


BRONCHITIS.  199 

In  the  early  stage  when  there  is  substernal  pain  with  little 
or  no  expectoration,  sedative  expectorants,  like  ipecac,  the  veg- 
etable salts  of  potassium,  antimony,  and  apomorphine  are  indi- 
cated ;  and  it  is  well  to  combine  with  them  an  opiate  to  check 
the  harassing  cough. 

^   Potass,  citi-at.,  ^ss  ; 

Apomorphinfe  hydrochlor.,  pjr.  j  ; 
Syr.  ipecac,  f  ^ss; 
Succi  limonis,  f^ij  ; 

Syr.  simp.,  q.  s.  ad  fsiv.— M.     (Wood.) 
Sig. — A  dessertspoonful,  in  water,  every  three  hours. 

Or— 

^   Vini  ipecacuanhae,  f  gij  ; 
Liq.  potass,  citrat.,  f|iv  ; 
Tinct.  opii  camph., 
Syr.  acacise,  aa  fgj.— M.     (DaCosta.) 
Sig. — Tablespoonful  thrice  daily. 

In  severe  cases  with  dyspnoea,  inhalations  from  a  steam 
atomizer  often  give  relief.  Wine  of  ipecac  (with  twice  its 
volume  of  water),  tincture  of  lobelia,  or  tincture  of  conium 
may  be  employed  for  this  purpose. 

In  the  later  stages,  when  expectoration  has  been  established, 
stimulating  expectorants  are  useful,  such  as  ammonium  chlo- 
ride, squills,  terpiu  hydrate,  terebene,  tar,  or  eucalyptus. 

R    Morphinse  sulphatis, 

Potassii  cyanidi,  aa  gr.  iss  ; 

Terpini  hydratis,  gr.  xl  ; 

Olei  eucalypti,  f3j. 
Pone  in  capsulas  No.  xx. 
Sig. — One  every  two  hours. 

Or— 

I^   Tiuct.  opii  camph.,  fjij  ; 
Syr.  prun.  virgin.,  fjiss  ; 
Syr.  picis  liquidise,  q.  s.  ad  f  ^iv. — M. 
Sig, — A  tablespoonful  thrice  daily. 

Or— 

1^   Terebeni,  f.^ss.     . 
Sig.  —Five  drops  on  sugar,  gradually  increased  to  ten  thrice  daily. 


200  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

Chronic  Bronchitis. 

(Chronic  Bronchial  Catarrh,  Winter  Cough.) 

Etiology. — It  may  result  from  the  continuation  of  an 
acute  attack  ;  but  more  frequently  it  develops  gradually  in 
association  with  gout,  alcoholism,  or  chronic  heart  or  kidney 
disease.     It  is  especially  common  in  the  old. 

It  is  an  associated  condition  in  emphysema,  phthisis,  chronic 
interstitial  pneumonia,  and  in  many  cases  of  asthma. 

Pathology. — The  mucous  membrane  of  the  bronchi  is 
sometimes  thickened  and  roughened  from  an  overgrowth  of 
the  connective  tissue ;  in  other  cases  the  mucosa  is  thin  from 
atrophic  changes.  The  surface  is  usually  covered  with  muco- 
pus  ;  ulcers  are  occasionally  noted. 

Long-standing  bronchitis  leads  to  dilatation  of  the  tubes 
(Bronchiectasis)  and  to  emphysema. 

Symptoms. — Persistent  cough,  and  more  or  less  muco-puru- 
lent  expectoration  ;  a  sense  of  soreness  behind  the  sternum. 
Fever  is  usually  absent,  and  unless  the  disease  is  very  severe, 
the  general  health  may  be  fairly  well  preserved.  Dyspnoea 
on  exertion  is  a  troublesome  symptom  ;  it  however  belongs  more 
to  the  resulting  emphysema  than  to  the  bronchitis. 

Physical  Signs. — Unless  emphysema  has  developed,  in- 
spection, ])alpation,  and  percussion  give  negative  results. 

Auscultation  reveals  rales,  some  of  which  are  dry  and 
wheezing,  while  others  are  moist  and  bubbling. 

Special  Varieties. — (1)  Rheumatic  bronchitis.  (2)  Bron- 
chorrhoea.     (3)  Dry  catarrh. 

Rheumatic  Bronchitis. — This  form  occurs  in  those  of  a  rheu- 
matic diathesis,  and  is  characterized  by  severe  paroxysmal 
cough,  the  expectoration  of  scanty  tenacious  mucus,  and  by 
aching  pains  in  various  parts  of  the  chest.  It  is  especially  in- 
fluenced by  atmospheric  changes,  and  does  not  yield  to  the 
ordinary  treatment  of  bronchitis. 

Bronchorrhoea. — This  term  is  applied  to  cases  of  chronic 
bronchitis  which  are  associated  with  a  very  copious  expectora- 
tion. The  sputum  is  generally  muco-purulent,  and  sometimes 
very  oflPensive  (Fetid  bronchitis). 

Dry  Catarrh. — This  form,  described  by  Laenuec  as  catarrhe 


BRONCHITIS.  201 

sec,  is  characterized  by  severe  spells  of  coughing  which  are 
accompanied  by  little  or  no  expectoration.  It  is  generally 
seen  in  the  old  in  association  with  emphysema  or  asthma. 

Diagnosis.  Phthisis. — The  absence  of  fever,  of  hemorrhage, 
of  bacilli  in  the  sputa,  and  of  signs  indicating  consolidation 
will  serve  to  distinguish  chronic  bronchitis  from  phthisis. 

Bronchiectasis. — This  often  results  from  chronic  bronchitis. 
Very  profuse  fetid  sputa,  expelled  periodically  in  gushes,  and 
perhaps  physical  signs  of  cavity  over  the  main  bronchi,  poste- 
riorly, indicate  bronchiectasis. 

Emphysema. — Much  dyspnoea,  distention  of  the  chest,  hyper- 
resonance  on  percussion,  and  a  prolonged  feeble  expiration  on 
auscultation  indicate  emphysema. 

Sequels. — Emphysema,  bronchiectasis,  and  dilatation  of 
the  right  ventricle 

Prognosis. — Perfect  recovery  is  rarely  atta:inable,  but  the 
disease  is  not  incompatible  with  long  life. 

Treatment. — A  careful  regulation  of  the  hygiene;  this 
includes  attention  to  diet,  clothing,  bathing,  exercise,  etc. 
Bronchitis  dependent  on  heart  or  kidney  disease  will  require 
remedies  directed  to  those  organs.  The  general  vitality  is 
frequently  reduced,  and  tonics  like  cod-liver  oil,  hypophos- 
])hites,  iron,  quinine,  and  strychniue  are  often  valuable  adjuncts 
to  the  special  treatment.  A  change  of  climate  often  secures 
permanent  relief.  In  this  country  the  extreme  south-western 
territory,  including  New  Mexico,  Arizona,  and  Southern  Cali- 
fornia, possesses  many  atmospheric  advantages. 

Alteratives  like  iodide  of  potassium  (gr.  v— x  thrice  daily)  are 
often  serviceable  in  chronic  bronchitis  with  little  expectoration. 

Counter-irritants — blisters,  tincture  of  iodine,  or  croton  oil — 
prove  useful. 

Stimulating  expectorants — chloride  of  ammonium,  terebene, 
tar,  eucalyptus,  oil  of  sandalwood,  and  copaiba — are  generally 
indicated  : — 

R    Strychniua;  sulphatis,  gr.  ss; 

Codeinte,  gr.  vj  ; 

Terebeni, 

Olei  santali,  aa  f^ss. 
Pone  in  capsulas  No.  xii. 
Sig. — One  every  three  hours. 


202  DISEASES   OF   THE   EESPIRATOEY   SYSTEM. 

Or— 

^  Copaibce,  ^iij  ; 

Acaciee  et  sacchar.  alb.,  aa  q.  s.  ; 
Spt.  lavandulpe  comp.,  fgss  ; 
Aquee,  q.s.  ad  fgvj. — M. 
Sig. — A  tablespoonful  thrice  daily. 

Or— 

^   Apomorpbinfe  h3-drochlor.,  gr.  i  ; 
Syi'.  prun.  A'irg.,  f5ij  ; 

Syr.  picis  liquida?,  fgiv. — M.     (Murkell,,) 
Sig. — A  tablespoonful  thrice  daily. 

The  method  of  treating  chronic  bronchitis  by  inhalations, 
which  has  been  so  ably  advocated  by  Dr.  Murrell  of  London, 
is  extremely  usefid,  especially  in  patients  with  weak  stomachs, 
in  whom  syrups  should  be  avoided. 

Wine  of  ipecac  (with  twice  its  volume  of  water),  terebene 
(with  equal  parts  of  benzoinol  or  liquid  vaseline),  creosote,  or 
carbolic  acid  may  be  so  employed. 

^   Acid,  carbol.,  gr.  xxx  : 

Tinct.  opii  camph.,  f5iij.— M.    (X.  S.  Davis.) 
Sig. — A  fluid  drachm  with  half  a  pint  of  hot  water  in  the  inhaler, 
thrice  daily. 

Fibrinous  Bronchitis. 

(Croupous  Bronchitis,  Pseudo-membranous  Bronchitis.) 

DEFiNiTioif. — Aprimary  inflammatory  disease  of  the  bronchi 
associated  with  the  formation  of  false  membrane. 

Etiology, — The  causes  are  unknown.  jNIale  sex,  early 
manhood,  and  chronic  pulmonary  disease,  like  phthisis,  emphy- 
sema, and  pleurisy,  appear  to  be  predisposing  factors. 

Pathology. — The  disease  is  often  limited  to  a  certain  num- 
ber of  bronchi.  Some  of  the  affected  tubes  are  found  filled 
with  a  fibrinous  exudate,  while  others  are  found  empty  and 
show  a  loss  of  epithelium.  The  casts  are  usually  expelled  in 
the  form  of  whitish  balls,  and  when  unrolled  in  water  present 
branching  moulds  of  the  divisions  and  subdivisions  of  the 
affected  bronchi.  On  close  examination  they  are  found  to  be 
hollow  and  laminated.  Under  the  microscope,  a  homogeneous 
or  fibrillated  membrane  is  observed,  imbedded  in  which  are 


DILATATION    OF   THE   BEONCHIAL   TUBES.  203 

leucocytes,  fat-drops,  particles  of  pigment,  epithelial  cells,  and 
occasionally  Ley  den's  octahedral  crystals. 

Symptoms. — Acute  and  chronic  forms  are  recognized.  The 
former  is  rare,  and  manifests  the  symptoms  of  a  severe  attack 
of  acute  bronchitis,  but  the  sputa  contain  fibrinous  casts,  and 
there  is  marked  dyspnoea. 

The  chronic  form  is  characterized  by  severe  cough,  parox- 
ysms of  dyspnoea,  and  the  expectoration  of  fibrinous  plugs. 
The  physical  signs  are  those  of  chronic  bronchitis.  The  disease 
often  lasts  a  few  weeks,  and  then  disappears  to  return  again  at 
definite  periods. 

Prognosis. — In  the  acute  variety  the  prognosis  must  be 
guarded  :  death  frequently  results  from  sufibcation. 

The  chronic  variety  runs  a  very  protracted  course. 

Treatment. — In  the  acute  disease,  the  atmosphere  of  the 
room  should  be  kept  moist  and  uniformly  warm.  Calomel 
(gr.  I  every  two  hours)  may  be  administered  as  in  other  mem- 
branous inflammations,  and  may  be  followed  by  iodide  of 
potassium.  Inhalations  of  alkaline  vapors  (lime-water)  exert 
a  solvent  effect.  Coimter-irritants  should  be  applied  to  the 
chest.     Emetics  sometimes  aid  in  the  expulsion  of  casts. 

In  the  chronic  form  iodide  of  potassium  may  be  given  in 
conjunction  with  stimulating  expectorants. 

DILATATION  OF  THE  BRONCHIAL  TUBES. 

(Bronchiectasis.) 

Definition. — A  universal  or  circumscribed  dilatation  of 
the  bronchi. 

Etiology. — Chronic  inflammation  of  the  tubes  and  the 
contraction  of  surrounding  pulmonary  tissue  are  the  prime 
causes  ;  hence,  it  is  generally  secondary  to  chronic  bronchitis, 
phthisis — particularly  fibroid — chronic  interstitial  pneumonia, 
and  chronic  pleurisy  with  adhesions. 

Pathology. — The  dilatation  results  from  weakening  and 
atony  of  the  tubes,  and  from  their  subjection  to  strain  in 
coughing,  or  to  the  traction  of  shrinking  connective  tissue,  as 
in  fibroid  phthisis. 

Two  forms  are  noted  :    (1)  The  cylindrical  form,  in  which 


204  DISEASES   OP   THE   RESPIRATORY  SYSTEM. 

the  tubes,  particularly  those  of  medium  size,  are  uniformly 
dilated  in  one  or  both  lungs ;  and  (2)  the  saccular  form,  in 
which  the  tubes  swell  out,  here  and  there,  into  circumscribed 
dilatations  which  may  reach  several  inches  in  diameter.  This 
form  is  especially  noted  in  fibroid  phthisis.  The  walls  of  the 
bronchiectatic  cavity  are  extremely  atrophied,  the  surface  is 
generally  smooth  and  shining,  but  ulcerations  are  not  un- 
common. 

Symptoms. — Cough,  dyspnoea,  and  copious  expectoration. 
The  last  is  characteristic ;  it  is  apt  to  occur  jaeriodically  in 
gushes  ;  the  material  has  a  highly  offensive  odor,  and  when 
allowed  to  stand  in  a  glass  vessel  separates  into  three  layers  : 
an  upper  layer  of  dirty  brown  froth,  a  middle  layer  of  turbid 
mucus,  and  an  under  layer  of  decomposed  pus.  Microscopi- 
cally it  contains  pus  corpuscles,  fat  crystals,  crystals  of  hsema- 
toidin,  and  numerous  microorganisms,  but  no  tubercle  bacilli. 
Elastic  fibres  are  rarely  found. 

Physical  Signs. — In  the  cylindrical  variety  the  signs  are 
those  of  chronic  bronchitis.  The  saccular  variety  may  present 
the  signs  of  tuberculous  cavities,  localized  tympany,  cavernous 
breathing,  gurgling  r^les,  and  pectoriloquy. 

Diagnosis.  - — The  differentiation  of  bronchiectasis  from 
phthisis  is  difficult  and  often  impossible.  The  discovery  of 
tubercle  bacilli  always  indicates  phthisis.  Bronchiectatic  cavi- 
ties are  usually  located  in  the  lower  lobes,  and  rarely  in  the 
apices. 

Prognosis. — This  will  depend  on  the  primary  disease ; 
since  the  common  causes  are  louff-standing  bronchitis  and 
fibroid  phthisis,  there  can  be  little  hope  of  cure.  Amelioration 
is  all  that  can  be  expected. 

Treatment. — Tonics  are  often  indicated.  Stimulant  and 
antiseptic  expectorants  like  turpentine,  terebene,  eucalyptus, 
oil  of  sandalwood,  and  tar  are  sometimes  useful. 

Inhalations  of  terebeue,  carbolic  acid,  or  dilute  peroxide  of 
hydrogen  lessen  cough  and  destroy  the  fetid  odor  of  the  breath. 
Codeine  (gr.  ^)  may  be  employed  to  allay  cough. 


ASTHMA.  205 

ASTHMA. 

Definition, — Paroxysmal  dyspnoea  due  to  spasm  of  the 
tubes  or  to  swelling  of  their  mucous  membrane. 

Etiology. — Asthma  is  a  symptom  of  several  diseases,  but 
a  hypersensitive  condition  of  the  mucous  membrane  of  the  re- 
spiratory tract  appears  to  be  essential  to  its  production.  When 
this  condition  prevails,  asthma  may  be  induced  (1)  by  the  pul- 
monary congestion  of  cardiac  disease  (Cardiac  asthma) ;  (2) 
by  the  urseraic  intoxication  or  transient  pulmonary  oedema  of 
Bright's  disease  (Renal  asthma) ;  or  (3)  by  some  irritant  from 
without,  as  the  pollen  of  plants  (Hay  asthma).  (4)  Sometimes 
the  paroxysms  are  excited  by  the  most  trivial  causes,  as  an 
atmospheric  change  or  a  peculiar  odor,  and  to  this  form  many 
writers  restrict  the  term  asthma.  This  last  will  be  discussed 
under  the  head  of  essential  asthma. 

Essential  Asthma. 

(Bronchial  Asthma,  Nervous  Asthma,  Spasmodic  Asthma.) 

Etiology. — Nervous  temperament,  an  hereditary  tendency, 
early  life,  disease  of  the  naso-pharynx,  and  the  gouty  diathesis, 
are  predisposing  factors. 

Barometric  and  thermometric  changes ;  the  inhalation  of 
dust;  the  odor  of  certain  plants,  animals,  or  fruits;  excite- 
ment ;  reflex  irritation,  particularly  a  loaded  stomach ;  a 
change  of  locality ;  and  bronchial  catarrh,  are  exciting  causes. 

Pathology. — The  disease  is  a  pure  neurosis,  and  tlie  par- 
oxysms probably  result  from  a  spasm  of  the  smaller  tubes,  or 
turgescence  of  their  mucous  membrane. 

Symptoms. — The  paroxysms  often  appear  suddenly,  but  in 
some  cases  certain  symptoms  precede  and  give  warning  of  the 
approaching  attack  ;  among  these  are  chilliness,  flatulence, 
sneezing,  and  a  copious  discharge  of  pale  urine.  The  patient 
is  often  seized  at  night.  There  is  a  sense  of  oppression  and 
anxiety  followed  by  dyspnoea  so  intense  that  he  runs  to  the 
window  for  air,  or  sits  upright  with  his  arms  in  such  a  position 
that  he  can  bring  into  play  the  auxiliary  muscles  of  respiration. 
The  face  is  pale,  the  lips  blue,  the  eyes  prominent  and  con- 


206  DISEASES   OF   THE   RESPIRATOSY  SYSTEM. 

gested,  and  the  body  cold  and  covered  with  sweat.  The  re- 
spirations are  not  rapid,  but  labored  and  noisy.  Cough  is  often 
present  and  is  associated  with  the  expectoration  of  scanty 
viscid  mucus.  On  close  examination  little  grayish  balls  are 
noted  in  the  sputum,  and  when  unravelled,  they  are  found  to 
be  composed  of  delicate  spirals  of  mucus,  which  have  been 
moulded  in  the  finer  bronchioles  (Curschmann's  spirals). 

Fig.  16 


Curschmann's  Spirals,    o,  Central  fibre. 

Microscopic  examination  also  reveals  octahedral  crystals 
similar  to  those  found  in  leukaemia  (Charcot-Leyden  crystals). 

The  paroxysms  may  last  from  a  few  minutes  to  many  hours, 
and  may  recur  for  several  successive  nights,  or  may  disappear 
entirely  for  weeks  or  months. 

Physical  Signs. — Inspection  reveals  evidences  of  dyspnoea 
and  distention  of  the  chest. 

Percussion  generally  yields  hyper-resonance. 

Auscultation. — A  prolonged,  high-pitched,  wheezing  expira- 
tion, with  abundant  sonorous  and  sibilant  rales.  The  expira- 
tory wheezing  may  be  audible  over  the  entire  room. 

Diagnosis. —  Cardiac  and  renal  asthma  are  to  be  distin- 
guished from  essential  asthma  by  the  history,  and  by  the  evi- 
dence of  organic  heart  or  kidney  disease. 

Hay  asthma  is  recognized  by  the  associated  coryza  and  by 
its  periodic  occurrence  every  spring  or  fall. 


ASTHMA.  207 

Laryngeal  ohstrudion  from  foreign  bodies,  croup,  j^aralysis 
of  the  vocal  cords,  or  osdema. — The  dyspnoea  is  with  iuspi ra- 
tion, and  the  chest  instead  of  being  distended  is  retracted, 
especially  at  the  base.  , 

Sequels.  —  Emphysema  invariably  follows  when  the 
asthma  is  of  long  duration  ;  it  results  from  the  tension  to 
which  the  vesicles  are  subjected  during  the  expiratory  effort. 
Dilatation  of  the  right  ventricle  is  also  a  remote  sequel. 

Prognosis.  —  The  disease  does  not  prove  fatal  except 
through  complications  or  sequelse.  In  young  persons  without 
an  inherited  tendency  the  prognosis  should  be  guardedly 
favorable ;  it  frequently  subsides  at  puberty.  Cases  associated 
with  some  definite  reflex  cause,  as  nasal  obstruction,  often 
recover  when  the  latter  is  removed.  The  older  the  patient,  the 
greater  the  inherited  tendency^  the  more  imfavorable  becomes 
the  prognosis. 

Treatment.  The  Attack. — Prompt  relief  often  follows 
the  inhalation  of  nitrite  of  amyl  (five  or  six  drops  in  a  glass 
or  on  the  handkerchief),  iodide  of  ethyl  (twenty  to  thirty 
drops),  or  a  few  whiffs  of  chloroform.  Smoking  cigarettes  of 
belladonna  and  stramonium  leaves  wrapped  in  nitre-paper — 
paper  which  has  been  soaked  in. a  saturated  solution  of  salt- 
petre and  dried — ^will  often  suffice  in  mild  attacks.  Nitre- 
paper  may  be  burned  in  the  room  and  the  fumes  inhaled. 

The  application  of  dry  cups  or  thin  poultices  to  the  chest  is 
often  a  valuable  adjunct  to  the  treatment.  Morphine  (gr.  |— j) 
with  sulphate  of  atropine  (gr.  yl^)  will  often  cut  short  an 
attack.  Internally,  sedatives  like  Hoffmann's  anodyne  (5ss), 
tincture  of  lobelia  ("L  xx),  and  bromide  of  potassium  (gr.  xxx), 
are  sometimes  useful. 

R    Tinct.  belladonnse, 

Tinct.  lobelise,  aa  f^iiss ; 
Spiritus  sether.  comp., 
Tinct.  opii  camph.,  aa  f^vj  ; 
Syrup,  prun.  Virginiante,  q.  s.  ad  f^iv. — M. 
Sig. — A  dessertspoonful  every  three  hours. 

The  Interval. — Careful  search  should  be  made  for  some  re- 
flex irritation,  especially  in  connection  with  the  naso-pharynx. 
An  easily-assimilable  diet  must   be   selected ;    in   nocturnal 
13 


208  DISEASES   OF   THE   EESPIKATOEY   SYSTEM. 

asthma  the  evening  meal  should  be  very  light.  Graduated  ex- 
ercise and  frequent  bathing,  followed  by  friction  of  the  skin, 
will  add  to  the  general  vigor.  A  change  of  climate  is  de- 
sirable, but  there  is  no  fixed  rule  in  the  selection  of  locality. 
Many  asthmatics  do  well  in  the  city,  but  a  dry  atmosphere 
and  a  high  altitude  are  better  suited  to  the  majority.  Busey 
claims  excellent  results  from  the  habitual  wearing  of  an  oil- 
silk  jacket  in  asthma  associated  with  bronchitis.  Among  the 
remedies  arsenic  and  iodide  of  potassium  hold  a  liigh  place  as 
alteratives.  Fowler's  solution  (three  drops,  gradually  increased 
to  ten  or  more,  thrice  daily),  or  five  to  ten  grains  of  the 
iodide  may  be  administered  over  long  periods.  Nitroglycerin 
(gr.  j^q),  or  nitrite  of  sodium  (gr.  iij-v  thrice  daily)  often  gives 
immunity  for  long  periods. 

HAY  ASTHMA. 

(Hay  Fever,  Autumnal  Catarrh,  Rose  Cold.) 

Definition. — A  catarrhal  affection  of  the  respiratory  tract, 
usually  occurring  periodically  every  spring  or  autumn,  excited 
by  the  action  of  some  atmospheric  irritant  upon  a  hyperses- 
thetic  mucous  membrane,  and  characterized  by  coryza,  bron- 
chitis, and  asthmatic  seizures. 

Etiology. — An  inherited  tendency,  male  sex,  nervous  tem- 
perament, indoor  life,  and  chronic  nasal  catarrh  are  predis- 
posing factors.  The  attack  as  a  rule  occurs  in  the  autumn 
(Autumnal  catarrh),  or  in  the  spring  (Rose  cold),  and  is  excited 
by  certain  dusts,  vapors,  or  odors.  The  pollen  of  plants  seems 
to  be  a  common  excitant.  The  seizures  may  occur  at  any 
time  if  the  peculiar  irritant  is  present. 

Pathology. — An  essential  feature  is  the  hypersensitive 
condition  of  the  mucous  membrane,  and  this  is  often,  though 
not  invariably,  associated  with  hypertrophic  rhinitis. 

Symptoms. — Redness  of  the  conjunctivse  and  swelling  of 
the  eyelids ;  pruritus  of  the  pharynx,  nose,  and  eyes ;  sneez- 
ing ;  obstruction  of  the  nostrils ;  watering  of  the  eyes ;  a 
copious  discharge  of  mucus  from  the  nose  ;  headache  ;  cough  ; 
and  asthmatic  attacks  are  the  usual  phenomena. 

Itose  cold  usually  begins  in  May  or  June  and  runs  to  the 


¥ 


PULMONARY    EMPHYSEMA.  209 


latter  part  of  July.     Autumnal  catarrh  begins  in  tlie  latter 
part  of  August  and  ends  with  the  first  frost. 

Prognosis. — The  disease  runs  an  indefinite  course,  and 
rarely,  if  ever,  proves  fatal.  Cases  which  are  associated  w-ith 
chronic  rhinitis  often  permanently  recover  on  the  removal  of 
the  latter.  In  other  cases,  the  prognosis  as  regards  immu- 
nity from  future  attacks  is  unfavorable. 

Treatment. — Careful  search  should  be  made  for  chronic 
nasal  disease,  and  if  found,  appropriate  treatment  instituted. 

A  change  of  climate  during  the  period  of  susceptibility 
exempts  most  patients.  A  sea-voyage  or  a  sojourn  in  some 
high-mountain  district,  like  the  White  Mountains,  Adiron- 
dacks,  Catskills,  or  Alleghanies  may  be  recommended. 

Tonics  are  usually  indicated,  and  quinine,  arsenic,  and 
strychnine  are  often  very  useful  when  administered  before  and 
during  an  attack.  To  allay  itching  and  lachrymation,  the 
eyes  may  be  washed  with  a  solution  of  boric  acid  (gr.  x  to  Sj), 
or  sulphate  of  zinc  (gr.  i-ij  to  Ij).  Sneezing,  nasal  fulue^^s, 
and  discharge  are  often  relieved  by  medicated  sprays.  A  solu- 
tion of  cocaine,  or  the  following  may  be  employed : — 

^   Menthol,  3j-5ij  ; 

01.  amygd.  dulc.  vel  benzoinol,  f  ^ij-M. 
Sig. — Spray  hito  the  nose  and  throat  every  few  hours. 

PULMONARY  EMPHYSEMA. 

Definition. — Abnormal  distention  of  the  lungs  with  air. 

Varieties. — (1)  Interlobular  emphysema :  This  form  is 
rare,  and  results  from  the  rupture  of  the  lung  and  escape  of 
air  into  the  interstitial  tissue.  (2)  Compensatory  emphysema  : 
When  a  lung  or  a  part  of  a  lung  is  disabled  from  any  cause, 
the  healthy  portions  distend  and  do  vicarious  work.  (3) 
Atrophic  or  senile  emphysema:  In  old  people  the  solids  of 
the  lung  atrophy,  so  that  a  relative  increase  of  air  results. 
(4)  Hypertrophic  emphysema.  The  last  three  varieties  are 
included  under  the  term  vesicular  emphysema. 

14 


210  DISEASES    OF   THE    RESPIRATORY   SYSTEM. 

Hypertrophic  Emphysema. 

Defixitiox. — A  pulmouary  disease  characterized  anatomi- 
cally by  dilatation  of  the  air-vesicles  and  atrophy  of  their 
walls  ;  and  clinically  by  dyspnoea,  enlargement  of  the  thorax, 
hyper-resonance,  and  weak  breathing. 

Etiology. — Congenital  weakness  of  the  lung  structure — 
probably  a  defective  development  of  elastic  tissue — is  an  im- 
portant predisposing  factor.  This  predisposition  may  be  trans- 
mitted through  several  generations. 

In  forced  expiration,  the  air  cannot  escape  with  sufficient 
rapidity  through  the  narrow  glottis,  and  the  backward  pres- 
sure stretches  the  air-vesicles ;  hence,  the  obstinate  cough  of 
chronic  bronchitis,  the  expiratory  straining  of  asthma,  and 
occupations  which  necessitate  forced  expiration,  like  playing 
on  wind  instruments  and  glass-blowing,  are  causal  factors. 

Pathology. — The  lungs  are  enlarged,  and  do  not  collapse 
when  the  thorax  is  opened.  In  bad  cases  the  free  margins  are* 
studded  with  large  bullae  or  blebs  which  have  resulted  from 
the  rupture  of  a  number  of  vesicles  into  a  common  sac.  The 
organs  are  pale,  and  have  a  soft  cotton-like  feel.  Microscopic 
examination  reveals  atrophy  of  the  vesicular  walls,  a  dimin- 
ished amount  of  elastic  tissue,  and  more  or  less  obliteration  of 
the  pulmonary  capillaries.  This  last  condition  leads  to  in- 
creased tension  in  the  pulmonary  artery  and  to  secondary 
hypertrophy  of  the  right  ventricle. 

Symptoms. — The  disease  generally  manifests  itself  in  middle 
life,  but  it  is  not  infrequently  observed  in  the  young.  Dys- 
pnoea, increased  by  exertion ;  cyanosis,  often  extreme  during 
attacks  of  acute  bronchitis  ;  and  cough,  from  the  associated 
bronchitis,  are  the  usual  symptoms.  In  advanced  cases  drojDsy 
may  result  from  cardiac  failure. 

Physical  Signs. — The  neck  is  short,  and  the  sterno- 
cleido-mastoids  prominent.  The  thorax  is  likewise  short,  but 
broad  especially  in  its  autero-posterior  diameter.  This  con- 
figuration has  given  rise  to  the  term  "  barrel-shaped"  chest. 
On  respiration  there  is  little  expansion,  but  an  elevation  of 
the  thorax  as  a  whole.  The  ajDCx-beat  is  invisible,  but  an 
abnormal  pulsation  is  often  noted  in  the  epigastrium. 


PULMONARY  EMPHYSEMA.  211 

Palpation. — Diminished  vocal  fremitus. 

Percussion.  —  Increased  resonance.  The  upper  level  of 
hepatic  dulness  is  depressed,  and  the  area  of  cardiac  dulness 
may  be  almost  obliterated. 

Auscultation. — Inspiration  is  short,  expiration  is  prolonged 
and  low-pitched,  or  inaudible.  Rales  resulting  from  the  asso- 
ciated bronchitis  are  frequently  heard.  The  pulmonary  second 
sound  is  accentuated. 

Complications. — Bronchitis,  asthma,  dilatation  of  the 
right  ventricle,  and  later,  tricuspid  regurgitation  and  dropsy. 

Diagnosis.  Chronic  Bronchitis. — The  dyspnoea,  thoracic 
enlargement,  hyper-resonance,  and  prolonged  expiration  sepa- 
rate emphysema  from  bronchitis. 

Pneumothorax. — This  is  almost  invariably  unilateral,  the 
resonance  is  tympanitic,  and  metallic  tinkling  and  bell- 
tympany  are  obtained  on  auscultation. 

Peognosis. — The  disease  is  generally  incurable ;  but  its 
advance  may  be  stayed  by  relieving  the  primary  condition. 
Emphysema  runs  a  long  course  and  is  in  itself  rarely  fatal, 
but  death  may  result  from  heart  failure  and  dropsy,  or  from 
intercurrent  pneumonia. 

Treatment. — The  remedies  advocated  in  chronic  bron- 
chitis and  asthma  are  often  applicable  here.  The  patient 
should  be  placed  under  the  most  favorable  hygienic  conditions. 
Iodide  of  potassium  (gr.  x  thrice  daily)  is  often  used  empiri- 
cally, and  sometimes  relieves  the  dyspnoea  and  cough.  Iron 
is  indicated  in  the  ansemic.  Strychuine  (gr.  4V~xo)  ^^  a  valu- 
able respiratory  and  cardiac  stimulant,  and  may  be.  combined 
with  digitalis  when  there  are  symptoms  of  heart  failure. 

^   Strychnin,  sulph.,  gr.  ^  ; 

Pulv.  digitalis, 

Pulv.  scillye, 

Ferri  reduct.,  aa  gr.  xx.— M. 
Ft.  in  pil.  No.  xx. 
Sig. — One  thrice  daily. 

The  inhalation  of  oxygen,  or  the  inspiration  of  compressed 
air  followed  by  expiration  into  rarefied  air  is  sometimes  a  useful 
measure. 


212  DISEASES   OF   THE   EESPIEATORY  SYSTEM. 

HEMOPTYSIS. 

(Bronchorrhagia,  Broncho-pulmonary  Hemorrhage.) 

Defixitiox. — The  expectoration  of  blood. 

Etiology. — (1)  Vicarious  menstruation  (rare).  (2)  Trau- 
matism. (3)  Inflammatory  diseases  of  the  respiratory  tract, 
especially  phthisis  and  pneumonia.  (4)  The  rupture  of  an 
aortic  aneurism.  (5)  Obstruction  to  the  venous  circulation 
as  in  chronic  heart  and  liver  disease.  (6)  Malignant  disease 
of  the  lung.  (7)  A  dyscrasia  of  the  blood,  as  in  purpura,  the 
infectious  fevers,  hsemophilia  (bleeder's  disease),  and  scurvy. 
(8)  It  occasionally  occurs  in  young  people  without  obvious 
cause. 

Symptoms. — Sometimes  the  bleeding  is  preceded  by  cough, 
dyspnoea,  or  substernal  warmth  or  tenderness,  but  often  there 
is  no  premonition,  and  the  first  indication  is  the  presence  of  a 
warm  salty  fluid  in  the  mouth.  The  blood  is  generally  raised 
by  coughing,  and  is  bright  red  and  frothy.  It  is  alkaline  in 
reaction,  and  intimately  mixed  with  air  and  mucus.  The 
hemorrhage  is  rarely  profuse  unless  it  results  from  the  rupture 
of  an  aortic  aneurism  or  the  ulceration  of  a  large  vessel  in  ad- 
vanced phthisis.  Auscultation  of  the  chest  reveals  bubbling 
rales.  The  subsequent  expectorations  are  tinged  with  blood, 
and  if  much  is  swallowed  it  may  excite  vomiting  or  pass  into 
the  intestine  and  impart  a  tarry  appearance  to  the  stools. 

Diagnosis. — HcBinoptysis  must  be  distinguished  from  hoema- 
temesis : — 

HEMOPTYSIS.  f  Hematemesis, 

History  of  some  chest  disease.        History  of  some  abdominal  dis- 

j      ease. 
The  blood  is  ejected  by  coughing,  i  The  blood  is  ejected  by  vomiting. 
The    blood    is    bright    red    and    The  blood  is  dark,  and  dense  or 

frothy.  I      clotted. 

The  blood  is  mixed  with  sputum.    The  blood  is  mixed  with  food. 
The  blood  is  alkaline  in  reaction.  '  Tbe  blood  is  acid  in  reaction. 
The    subsequent    expectorations  ;  The    subsequent    expectorations 


are  tinged  with  blood,  and  the 
stools  are  rarely  tarry. 
Auscultation  reveals  rales. 


contain  no  blood,  and  the  stools 
are  frequently  tarry. 
Auscultation  gives  negative  re- 
sults. 


I 


PULMONARY    APOPLEXY.  213 

Prognosis. — Hsemoptysis  is  rarely  the  cause  of  death  in 
the  disease  in  which  it  occurs.  In  phthisis  the  symptoms 
often  improve  after  a  moderate  hemorrhage.  On  the  other 
hand,  in  aneurism,  advanced  phthisis,  and  abscess  and  gan- 
grene of  the  lung,  the  bleeding  may  prove  fatal. 

Treatment. — Absolute  rest  and  the  avoidance  of  excite- 
ment. The  shoulders  should  be  elevated  ;  an  ice-bag  may  be 
placed  on  the  chest,  and  pieces  of  ice  may  be  held  in  the  mouth, 
and  slowly  swallowed.  Morphine  is  generally  required  as  a 
sedative;  it  may  be  given  hypodermically  with  ergotin  (gr. 
v-x)  or  with  the  fluid  extract  of  ergot  [t^  x-xx).  Gallic  acid 
(gr.  x-xx)  may  be  given  by  the  mouth.  Astringent  sprays 
are  useless.  A  saline  purge  may  act  beneficially  by  inviting 
blood  away  from  the  congested  organ.  A  firm  ligature  around 
one  or  both  legs  retards  the  flow  of  venous  blood,  and  so  aids 
in  arresting  the  hemorrhage. 

When  the  bleeding  is  not  profuse,  but  frequently  repeated, 
the  following  internal  remedies  are  ejBScient :  Acetate  of  lead 
gr.  ij  with  powdered  opium  gr.  ^,  gallic  acid  (gr.  x-xx),  fluid 
extract  of  hamamelis  (5j-5iij))  turpentine  (gtt.  x),  or — 

^  Acid,  gallic,  ^iiss  ; 

Acid,  sulph.  aromat.,  f^j  ; 
Glycerin.,  f^ss  ; 
Aquse,  q.  s.  ad  f  ^iv— M. 
Sig. — A  tablespoonful  thrice  daily. 

PULMONARY  APOPLEXY. 

(Hemorrhagic  Infarction  of  the  Lung.) 

Definition. — An  effusion  of  blood  into  the  pulmonary 
tissues. 

Etiology. — It  may  result  from  degeneration  of  the  pul- 
monary vessels,  but  it  is  most  trequently  due  to  an  embolus 
or  a  thrombus  in  one  of  the  branches  of  the  pulmonary  artery. 
The  embolus  is  usually  a  portion  ot  a  thrombus  which  has 
formed  in  the  heart  or  in  one  of  the  systemic  veins.  Occlu- 
sion of  the  vessel  causes  a  backward  flow  of  blood,  the  part 
becomes  engorged,  and  effusion  follows. 


214  DISEASES   OF  THE   UESPIRATOEY  SYSTEM. 

Pathology.  —  The  infarction  is  usually  located  in  the 
periphery  of  the  lung ;  it  is  conical  in  shape  with  its  apex 
pointing  inwards.  The  portion  affected  is  airless,  and  reveals 
an  infiltration  of  dark  blood.  Microscopic  examination  shows 
a  dense  aggregation  of  blood-corpuscles. 

If  it  does  not  prove  fatal,  absorption  and  subsequent  fibroid 
induration  result. 

Symptoms. — When  the  infarction  is  large  the  usual  symp- 
toms are  dyspnoea,  cough,  and  the  expectoration  of  dark  blood 
containing  few  air-bubbles.  These  symptoms  occurring  in 
chronic  heart-disease  are  especially  suggestive. 

Physical  Signs. — Very  large  infarctions  give  dulness  and 
bronchial  breathing. 

Teeatment. — The  condition  itself  is  not  amenable  to  treat- 
ment.    Remedies  should  be  directed  to  the  primary  disease. 

CONGESTION  OF  THE  LUNGS. 
Active  Congestion. 

Etiology. — This  results  from  increased  afflux  of  blood  to 
the  lungs.  Hypertrophy  of  the  heart,  violent  exercise,  moun- 
tain-climbing, the  inhalation  of  irritants,  and  mental  excitement 
occasionally  produce  it.  It  is  an  associated  condition  in  all 
severe  inflammatory  diseases  of  the  lungs.  In  the  vast 
majority  of  cases  it  marks  the  initial  stage  of  croupous  pneu- 
monia. 

Pathology. — The  lung  is  bright  red  in  color,  heavy,  and 
less  crepitant.  When  incised  and  pressed,  copious  frothy 
blood  exudes. 

Symptoms.  —  Flushed  face  ;  dyspuoea ;  short,  dry  cough^ 
followed  by  tenacious  blood-streaked  expectoration ;  and  a 
rapid,  full  pulse.  Physical  examination  reveals  slight  dulness, 
crepitant  rales,  and  broncho-vesicular  breathing. 

Treatment. — Rest ;  liquid  diet ;  wet  cups  to  the  chest. 

Internally. — Veratrum  viride  and  a  saline  purge. 


CONGESTION   OF   THE   LUNGS.  215 

Passive  Congestion. 

Etiology. — This  results  from  obstruction  to  the  flow  of 
blood  from  the  lungs  to  the  heart.  The  chief  cause  is  cardiac 
disease,  especially  fatty  degeneration,  dilatation,  and  mitral 
disease. 

Pathology. — The  lungs  are  dark  red  in  color,  and  often 
somewhat  oedematous.  When  the  condition  has  lasted  a  long 
time,  the  organs  become  brown,  dense,  and  tough  (brown  in- 
duration). Microscopic  examination  reveals  a  dilatation  of 
the  capillaries,  an  overgrowth  of  connective  tissue,  free  pigment 
granules,  and  degenerative  changes  in  the  bloodvessels. 

Symptoms. — Dyspnoea ;  hard  cough  ;  mucous  expectoration 
containing  pigmented  cells.  Physical  examination  reveals 
rales,  slight  dulnes<,  and  feeble  breathing. 

Treatment. — Remedies  should  be  directed  to  the  under- 
lying cardiac  disease.  The  aj^plication  of  dry  cups  often  gives 
temporary  relief.     Saline  laxatives  may  prove  useful. 

Hypostatic  Congestion. 

(Hypostatic  Pneumonia,  Splenization  of  the  Lung.) 

Definition. — A  congestion  of  dependent  portions  of  the 
lungs  occurring  in  asthenic  diseases  which  necessitate  a  pro- 
tracted recumbent  position. 

Etiology. — It  is  generally  observed  in  low  fevers  and  in 
chronic  wasting  diseases.  (1)  Blood-dyscrasia,  (2)  a  weak 
heart,  and  (3)  a  recumbent  position  are  the  causal  factors. 

Pathology. — The  lungs  are  dark  red  and  oedematous  pos- 
teriorly. The  oedema  and  increased  amount  of  blood  render 
the  organs  more  solid  and  less  crepitant.  They  never  show 
the  granular  appearance  of  croupous  pneumonia. 

Symptoms. — Dyspnoea,  cough,  and  scanty  expectoration. 

Physical  examination  reveals  slight  dulness,  subcrepitant 
rales,  and  feeble  bronchial  breathing. 

Treatment.— Efforts  should  be  made  to  prevent  the  de- 
velopment of  hypostatic  pneumonia  in  asthenic  disease  by 
frequent  change  of  position,  and  the  timely  use  of  such  cardiac 


216  DISEASES   OF    THE    RESPIRATORY    SYSTEM. 

stimulants  as  alcohol,  strychnine,  digitalis,  ammonia,  and  tur- 
pentine. When  already  present,  turpentine  stupes  or  dry  cups 
may  be  applied  externally,  and  one  or  more  of  the  above 
stimulants  administered  internally. 

CROUPOUS  PNEUMONIA. 

(Lobar  Pneumonia,  Pneumonitis,  Lung  Fever.) 

Definition. — An  acute  specific  disease,  characterized  ana- 
tomically by  an  inflammation  of  the  lungs,  followed  by  a 
rapid  infiltration  of  their  alveoli ;  and  manifested  clinically  by 
high  fever,  cough,  dyspnoea,  "rusty"  sputum,  and  physical 
signs  indicative  of  consolidation. 

Etiology. — Age,  sex,  and  climate  exert  but  little  predis- 
posing influence.  Lowered  vitality  from  bad  hygiene  or  from 
some  pre-existent  disease,  like  diabetes,  Bright's  disease,  or  one 
of  the  infectious  fevers,  favors  its  development.  One  attack 
renders  the  patient  more  liable  to  subsequent  infection.  Alco- 
holism is  a  strong  predisposing  factor.  Exposure  to  cold  and 
wet  often  precipitates  the  attack. 

The  exciting  cause  is  the  invasion  of  the  lung  by  pathogenic 
bacteria,  especially  by  Frankel's  diplococcus  pneumoniae. 

Pathology. — Anatomically  three  stages  have  been  recog- 
nized :  (1)  The  stage  of  congestion  ;  (2)  of  red  hepatization  ; 
(3)  of  gray  hepatization. 

Stage  1. — The  affected  portion  remains  distended  when  the 
chest  is  opened ;  it  is  of  a  deep-red  color,  and  is  more  resistant 
to  the  touch  than  the  normal  lung.  On  section,  a  frothy  blood- 
stained serum  freely  exudes.  Microscopic  examination  reveals 
a  dilated  and  tortuous  condition  of  the  capillaries,  swelling  of 
the  alveolar  cells,  and  a  slight  corpuscular  exudate. 

Stage  '2. — The  hepatized  portion  is  increased  in  volume,  is 
quite  firm,  is  of  a  dark-red  color,  and  so  heavy  that  it  sinks 
in  water.  It  is  very  friable,  and  the  torn  surface  presents  a 
granular  appearance  from  the  projection  of  the  fibrinous  plugs 
in  the  alveoli. 

Microscopic  examination  reveals  a  mesh  of  coagulated  fibrin, 
enclosing  numerous  red  blood-corpuscles  and  some  leucocytes ; 


CROtJPOtJS   PNEUMONIA.  21 1 

the  latter  are  also  noted  in  the  interlobular  tissue.  In  sections 
properly  treated  the  diploeoccus  is  detected. 

Stage  3. — The  red  color  gives  place  to  a  mottled  gray,  and 
the  solidified  lung  begins  to  soften.  The  change  in  color  is 
due  to  the  compression  of  the  capillaries,  to  the  disappearance 
of  red  corpuscles  and  their  replacement  by  leucocytes,  and  to 
fatty  degeneration  of  some  of  the  elements. 

In  favorable  cases  resolution  occurs  before  gray  hepatization 
has  far  advanced,  the  exudation  being  removed  by  absorption 
and  expectoration. 

In  unfavorable  cases  the  consolidated  lung  may  become  in- 
filtrated with  pus  (Purulent  infiltration) ;  it  may  become 
gangrenous ;  or,  very  rarely,  it  may  become  the  seat  of  fibroid 
induration  (Chronic  interstitial  pneumonia). 

Death  may  result  early  in  the  disease  from  the  generated 
blood-poisons,  or  from  rapid  diminution  of  the  respiratory 
siu'face. 

The  consolidation  usually  begins  at  the  base  and  extends 
upwards.  The  most  frequent  seat  is  the  lower  lobe  of  the 
right  lung.  The  bronchi  and  the  adjacent  pleura  are  involved 
in  the  inflammatory  process. 

Symptoms. — The  disease  usually  begins  with  a  decided 
chill  and  a  sharp  pain  in  the  side,  followed  by  a  rapid  rise  of 
temperature ;  the  latter  often  attains  its  maximum  (104°-105°) 
in  twenty-four  hours,  and. generally  continues  high,  with  slight 
diurnal  remissions,  until  the  ninth  day,  when  it  falls  by  crisis, 
frequently  reaching  the  norm  by  the  tenth  day.  Occasionally 
the  temperature  falls  by  lysis.  There  is  marked  dyspnoea; 
the  respirations  are  shallow  and  rapid,  ranging  from  40  to  80 
per  minute,  thus  making  the  ratio  between  respiration  and  the 
pulse  1  to  3  or  1  to  2.  Cough  is  a  prominent  symptom ;  at 
first  it  is  short  and  dry,  but  later  it  is  accompanied  by  bloody 
("  rusty'^),  translucent,  and  tenacious  sputa.  Microscoijically 
the  sputum  contains  red  blood-corpuscles,  their  free  pigment, 
pus-corpuscles,  dipiococci,  -and  other  microorganisms.  The 
face  is  flushed ;  the  lips  are  cyanosed  and  often  the  seat  of  an 
herpetic  eruption ;  the  tongue  is  heavily  furred ;  the  bowels 
are  constipated ;  and  the  urine  is  scanty,  high-colored,  de- 
ficient in  chlorides,  and  often  slightly  albuminous.     In  severe 


218  DISEASES    OF    THE    RESPIRATORY   SYSTEM. 

cases  delirium  is  rarely  absent.  Examination  of  the  blood 
usually  shows  marked  leucocytosis. 

Physical  Signs.  Inspection. — Diminished  expansion,  but 
no  bulging  of  the  interspaces  or  displacement  of  the  apex-beat. 

Palpation.  —  Diminished  expansion  and  increased  vocal 
fremitus. 

Percussion. — At  the  onset  there  may  be  tympany  over  the 
affected  area  from  diminished  intra-pulmonary  tension.  As 
consolidation  advances  the  note  becomes  remarkably  dulL 
Exaggerated  resonance  is  noted  around  the  hepatized  areas. 

Auscultation. — In  the  stage  of  congestion  fine  crepitant  rS,les 
are  heard  at  the  end  of  forced  inspiration ;  they  probably 
result  from  the  forcible  separation  of  adherent  vesicular  walls, 
and  disappear  when  the  lung  becomes  solidified.  Auscultation 
then  detects  increased  vocal  resonance,  and  harsh  breathing 
which  is  prolonged,  high-pitched,  and  tubular  in  expiration 
(bronchial). 

During  resolution  the  softened  exudate  produces  fine  moist 
rales — tlie  redux-crepitus. 

Atypical  CaSGS.  Senile  Pneumonia. — The  symptoms  often 
develop  insidiously ;  the  temperature  may  not  be  high  ;  the 
pulse  may  not  be  accelerated  ;  expectoration  is  often  absent ; 
the  signs  are  not  marked ;  delirium  is  common ;  weakness  is 
extreme;  and  death  from  exhaustion  is  the  most  frequent 
termination. 

Pneumonia  in  Children. — It  is  often  ushered  in  with  con- 
vulsions. Headache,  delirium,  stupor,  and  coma  are  promi- 
nent symptoms,  so  that  the  disease  may  simulate  meningitis. 
The  temperature  is  very  high  ;  expectoration  is  often  absent. 
The  disease  frequently  begins  at  the  apex  of  the  lung. 

Typhoid  Pneumonia. — Pneumonia  associated  Avith  typhoid 
symptoms,  —  headache,  muttering  delirium,  stupor,  a  dry, 
brown  tongue,  subsultus  tendinum,  carphologia,  a  rapid,  weak 
pulse,  and  high  fever  which,  in  favorable  cases,  falls  by  lysis. 
The  expectoration  is  often  like  prune-juice. 

Pneumonia  of  Drunkards. — The  onset  is  gradual ;  the  ex- 
pectoration is  like  prune-juice ;  the  temperature  is  not  high, 
but  a  violent  maniacal  delirium  commonly  develops  and  is 
followed  by  death  from  exhaustion. 


CROUPOUS    PNEUMONIA.  219 

Complications. — Pleurisy,  pericarditis,  malignant  endo- 
carditis, oedema  of  the  lungs,  delayed  resolution  (consolidation 
may  last  five  or  six  weeks,  and  then  disappear),  abscess  of  the 
lung,  gangrene  of  the  lung,  and  chronic  interstitial  pneumonia. 

Diagnosis.  Pleurisy. — Here  the  initial  chill  is  not  so 
marked  ;  the  fever  is  not  so  high  nor  the  pulse  so  rapid  ;  and 
there  is  no  "rusty" sputum  ;  but  bulging  and  displacement  of 
the  apex-beat  are  often  noted  on  inspection  ;  the  percussion-dul- 
ness  may  change  with  the  posture  of  the  patient ;  vocal  reso- 
nance and  vocal  fremitus  are  diminished ;  and  the  breathing 
is  distant  aud  weak. 

Acute  Phthisis. — Irregular  fever,  bacillus  tuberculosis  in  the 
sputum,  and  the  continuation  of  grave  symptoms  with  signs 
of  softeuing  after  the  ninth  or  tenth  day,  will  suggest  the 
diagnosis  of  tuberculosis. 

Pulmonary  Oedema. — Here  there  is  absence  of  chill,  fever, 
and  pain ;  the  expectoration  is  watery,  not  "  rusty ;"  both 
lungs  are  commonly  affected  ;  auscultation  reveals  abundant 
subcrepitant  rales  and  weak  breathing. 

Typhoid  Fever. — Typhoid  pneumonia  may  be  readily  mis- 
taken for  typhoid  fever  with  pneumonia ;  but  pneumonia  as  a 
complication  occurs  late  in  the  disease,  so  that  the  history  of 
the  onset  gives  much  assistance. 

Prognosis. — In  patients  previously  healthy  the  prognosis 
is  good.  At  the  extremes  of  life  the  outlook  is  grave.  In 
drunkards  the  disease  is  especially  fatal. 

In  individual  cases,  great  dyspnoea  and  cyanosis,  rapidly 
increasing  consolidation,  involvement  of  both  lungs,  mutter- 
ing delirium,  a  failing  pulse,  the  absence  of  leucocytosis,  and 
a  dark  sputum  are  unfavorable  factors. 

The  average  mortality  is  20  per  cent. 

Treatment. — Absolute  rest.  A  liquid  or  semi-liquid  diet 
(milk,  koumiss,  eggs,  broths,  beef  juice).  The  chest  should  be 
enveloped  in  a  cotton  jacket  covered  with  oiled  silk. 

Although  pneumonia  is  an  infectious  disease  which  produces 
widespread  disturbance  in  the  economy,  the  immediate  danger 
is  often  obstruction  to  the  pulmonary  circulation  ;  so  that  in 
the  stage  of  congestion,  when  the  pulse  is  full  and  strong, 
veratrum  viride  (1TL  iij-v  of  the  fluid  extract  every  hour  until 


220  DISEASES   OF  THE   RESPIBATORY  SYSTEM. 

the  pulse  softens)  is  a  valuable  remedy.  It  depresses  the 
heart,  dilates  the  systemic  vessels,  and  so  invites  blood  away 
from  the  eng:orged  lung.  In  the  very  robust,  venesection  may 
be  substituted  for  veratrum. 

In  consolidation,  the  right  ventricle  is  subjected  to  a  strain 
and  there  is  danger  of  heart  failure ;  hence  cardiac  stimulants 
are  indicated  in  this  stage.  The  tincture  of  digitalis  (gtt.  x 
every  two  or  three  hours,  being  guided  by  the  pulse)  may  be 
given  by  the  mouth  ;  when  the  stomach  is  irritable,  the  drug 
should  be  administered  hypodermically.  Strychnine  (gr.  -^) 
is  also  of  great  value  as  a  cardiac  and  respiratory  stimulant. 
Ammonia  is  useful  in  some  cases,  and  either  the  aromatic  spir- 
its or  the  carbonate  may  be  employed.  The  inhalation  of 
oxygen  sometimes  gives  much  relief.  ]Marked  cyanosis  with 
engorgement  of  the  right  ventricle  is  an  indication  for  vene- 
section. 

As  a  general  stimulant  and  food,  alcohol  is  often  indicated. 
In  typhoid  pneumonia  turpentine  (TTL  v)  may  be  associated 
with  the  alcohol. 

Pain  may  be  relieved  by  opium,  or  by  the  application  of 
wet  cups,  dry  cups,  an  ice-bag,  or  hot  fomentations. 

Delirium. — Apply  an  ice-bag  to  the  head,  and  administer 
bromide  of  potassium,  hyoscine.  musk,  or  camphor  internallv. 
"When  the  delirium  is  associated  with  high  fever,  a  cold  pack 
or  tepid  bath  Avill  often  control  it. 

Pyrexia. — Occasionally,  high  fever  will  require  treatment ; 
sponging,  a  cold  pack,  or  a  cold  bath  (80°)  may  be  employed. 
Antipyrin  (gr.  vj)  is  a  safe  and  efficient  remedy. 

Convalescence  should  be  guarded,  and  such  tonics  as  iron, 
quinine,  strychnine,  and  cod-liver  oil  will  be  found  useful  resto- 
ratives. 

In  delayed  resolution,  small  blisters  maybe  applied  over  the 
affected  areas,  and  iodide  of  potassium  may  be  administered 
internally.     Thus  : — 

Potass,  iodid.,  5j  ; 
Amnion,  cblor. .  jiss  ; 

Mist,  glycyrrhizfe  comp. ,  f3yj. — M.    (.Da  Costa. ) 
Sig. — Tablespoonful  four  times  a  day. 


CATARRHAL    PNEUMONIA,  221 

CATARRHAL  PNEUMONIA. 

(Broncho-pneumonia,  Lobular  Pneumonia,  Insular  Pneumonia.) 

Definition. — An  inflammation  of  the  terminal  bronchioles 
and  air-vesicles. 

Etiology. — It  is  most  frequently  observed  in  the  very- 
young  and  the  old.  It  is  a  common  sequel  of  the  specific 
fevers,  especially  of  whooping-cough,  measles,  influenza,  and 
diphtheria.  In  debilitated  subjects  it  may  occur  as  a  primary 
affection,  the  result  of  exposure. 

Another  group  of  cases  results  from  the  aspiration  of 
particles  of  food  into  the  smaller  bronchi  (aspiration  or 
deglutition  pneumonia).  This  accident  is  liable  to  occur 
whenever  the  sensibility  of  the  larynx  is  benumbed,  as  in 
apoplexy,  bulbar  palsy,  or  uraemia.  Cancer  of  the  throat 
and  operations  on  the  upper  air-passages  also  favor  its  occur- 
rence. The  pathogenic  bacteria  are  the  pneumococci,  the 
streptococci  and  staphylococci  of  suppuration,  and  the  bacillus 
of  influenza. 

Pathology. — As  a  rule,  both  lungs  are  involved.  On 
section,  small  projecting  areas  of  consolidation  are  noted  here 
and  there  around  the  finer  bronchioles.  Recent  patches  are 
reddish-brown  in  color,  firm,  and  smooth  or  finely  granular  ; 
later  they  become  grayish  and  soft.  The  terminal  bronchi 
are  filled  with  purulent  material. 

In  addition  to  these  solidified  areas,  there  are  other  small 
patches  of  collapsed  lung  which  are  airless,  firm,  and  bluish- 
red  in  color.  The  collapse  has  resulted  from  occlusion  of  the 
bronchus,  and  closely  resembles  consolidation ;  but  it  can,  as 
a  rale,  be  overcome  when  inflation  is  practised  by  means  of  a 
blowpipe  inserted  in  the  supplying  bronchus. 

Microscopic  examination  reveals  an  exudate  in  the  terminal 
bronchi  and  air-cells,  which  is  composed  of  leucocytes  and  des- 
quamated epithelium  in  various  stages  of  degeneratiou. 
The  walls  of  the  bronchi  are  also  infiltrated  with  leucocytes. 

When  compared  with  croupous  pneumonia,  the  contrast  is 
striking.  In  the  latter  the  lung  is  involved  en  masse  ;  the  con- 
solidation is  distinctly  granular,  and  is  composed  of  red  blood- 


222  DISEASES    OF    THE   EESPIEATORY   SYSTEM. 

corpuscles,  white  blood-corpuscles,  fibrin,  and  diplococci ;  the 
lining  epithelium  is  but  slightly  involved  ;  and  the  walls  of  the 
bronchi  are  not  infiltrated  with  leucocytes. 

Terminations. — (1)  Resolution  ;  the  exudate  undergoes 
fatty  degeneration  and  is  removed  by  absorption  or  expectora- 
tion. (2)  Tuberculosis.  Termination  in  phthisis  is  quite  com- 
mon ;  doubtless  in  many  cases  the  disease  was  primarily  tuber- 
culosis, and  in  others  the  exudate  became  a  good  soil  for  the 
development  of  tubercle  bacilli.  (3)  Abscess  or  gangrene; 
these  terminations  are  rare  except  in  pneumonias  resulting 
from  aspiration. 

Symptoms. — The  symptoms  are  often  masked  by  the  pri- 
mary disease.  The  onset  is  usually  gradual,  and  is  character- 
ized by  prostration,  cough,  and  fever.  The  last  is  moderately 
high  and  very  irregular  (101°-104°).  The  dyspnoea  is 
marked,  and  the  respirations  are  rapid — 50  to  80  per  minute  ; 
the  pulse  is  greatly  accelerated — 120  to  180  per  minute; 
cough  is  painful  and  accompanied  by  a  muco-purulent  ex- 
pectoration which  is  rarely  blood-streaked.  The  face  is  usu- 
ally pale  and  anxious,  and  the  lips  blue. 

Physical  Signs. — As  the  areas  of  consolidation  are  gene- 
rally small  and  scattered,  the  physical  signs  are  not  marked. 

Inspection  reveals  evidences  of  dyspnoea, — lividity,  playing 
of  the  nostrils,  prominence  of  the  sterno-cleido-raastoids,  and 
retraction  of  the  base  of  the  chest. 

Palpation  usually  gives  negative  results. 

Percussion  may  reveal  areas  of  dulness  in  one  or  both  lungs. 

Auscultation  reveals  fine  sibilant  (whistling)  or  subcrepitant 
rales,  and  areas  over  which  the  breathing  is  tubular,  or  bron- 
chial. 

Diagnosis. — The  following  table  will  show  the  clinical 
differences  between  catarrhal  and  croupous  pneumonias: — 


CATAREHAL    PNEUMONIA. 


223 


Cause  .  .  . 
Onset  •  .  . 
Fever   .     .     . 

,      Expectoration 
Physical  Signs 


Catarrhal  Pneumonia. 

Usually  secondary  to  bron- 
chitis. 

Gradual,  a  chill  generally 
absent. 

Moderately  high,  very  ir- 
regular, and  ending  by 
lysis  after  an  indefinite 
period. 

Muco-purulent. 

A  bilateral  disease.  Phy- 
sical signs  are  indistinct 
and  indicate  scattered 
areas  of  consolidation. 


Croupous   Pseujionia. 
A  primary  disease  excited 

by  the  diplococcus. 
Abrupt  onset  with  a  chill. 

High,  regular,  and  ending 
by  crisis  at  the  eighth  or 
ninth  day. 

"  Rusty,"  translucent,  and 
tenacious. 

A  unilateral  disease.  Phy- 
sical signs  are  distinct 
and  indicate  a  large  and 
uniform  consolidation. 


Acute  Phthisis. — In  this  disease  there  is  a  tuberculous 
broncho-j)neumonia  which  is  difficult  to  distinguish  from  sim- 
ple broncho-pneumonia.  A  family  history  of  tuberculosis,  an 
extensive  involvement  of  the  apices,  free  sweating,  haemop- 
tysis, long  duration,  and  bacilli  and  elastic  fibres  in  the 
sputa  are  the  diagnostic  phenomena  of  phthisis. 

Bronchitis. — In  simple  bronchitis  the  fever  is  not  high,  the 
dyspnoea  is  rarely  marked,  prostration  is  usually  absent,  and 
there  are  no  physical  signs  indicating  consolidation. 

Peognosis. — Always  guarded.  In  the  very  young,  very 
old,  and  debilitated  the  disease  is  commonly  fatal.  Many 
recover  from  the  pneumonia  following  the  infectious  fevers. 
Aspiration-pneumonia  is  commonly  fatal.  The  mortality  is 
difficult  to  estimate,  for  acute  phthisis  is  often  diagnosed 
catarrhal  pneumonia ;  it  is  probably  greater  than  in  croupous 
pneumonia,  and  varies  from  30  to  60  per  cent.  The  duration 
is  from  one  to  three  weeks ;  a  longer  duration  w^ould  suggest 
tuberculosis. 

Treatment. — The  disease  can  often  be  prevented  by  care- 
fully protecting  patients  suffering  from  bronchitis  and  infec- 
tious fevers.  In  the  latter  it  is  also  essential  that  the  naso- 
pharynx should  be  kept  clean  with  some  mild  antiseptic 
solution. 

The  room  should  be  well  ventilated,  but  free  from  draft, 


224  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

and  the  temperature  should  be  kept  uniformly  at  70°.  A 
moist  atmosphere  is  desirable,  and  an  apparatus  for  producing 
steam  may  be  improvised.  Tincture  of  iodine  may  be  applied 
locally,  and  the  chest  enveloped  in  a  cotton  jacket. 

The  diet  should  be  liquid  or  serai-liquid,  and  may  include 
milk,  junket,  koumiss,  eggs,  broths,  and  beef-juice.  Stimu- 
lants, wine  or  brandy,  are  usually  required  to  combat  the 
extreme  prostration. 

At  the  onset  a  laxative  should  be  administered,  and  calomel 
may  be  selected  (gr.  ^  every  hour  until  it  operates). 

Stimulating  expectorants  are  nearly  always  indicated,  and 
chloride  of  ammonium,  carbonate  of  ammonium,  squills,  or 
senega  may  be  employed. 

^   Amnion,  chlondi,  gr.  1 ; 
Spt.  setheris  nitrosi,  f§ss  ; 
Syr.  senegee,  f^iiss  ; 

Tinct.  cardamom,  comp.  el  aquse,  aa  q.  s.  ad  fgij. 

— M. 
Sig. — A  teaspoonful  every  two  or  three  hours  to  a  child  of  three 
years. 

Or— 

^  Ammon.  carb.,  gr.  xxiv ; 
Syr.  tolu.,  fsvj  ; 
Spt.  vini  gal.,  f  ^iij  ; 
Syr.  senegae,  f  ^iijss  ; 
Syr.  acacise,  q.  s.  ad  f.^iij. — M. 

(GoobnART  and  Starr.) 
Sig.— Teaspoonful  every  two  hours  to  a  child  of  two  or  thi-ee  years. 

Strychnine  is  often  invaluable  as  a  resj)iratory  and  cardiac 
stimulant ;  for  an  adult,  gr.  Jg-  may  be  given  three  or  four 
times  daily. 

The  accumulation  of  mucus  in  the  bronchial  tubes,  indicated 
by  extreme  cyanosis,  a  weak  pulse,  and  bubbling  rales,  will 
call  for  an  emetic ;  wine  of  ipecac  (sj-^ss),  or  apomorphine 
(for  an  adult  gr.  -^-^)  may  be  selected.  Nervous  symptoms — 
restlessness,  delirium,  etc. — will  often  be  relieved  by  a  cold 
pack  or  by  a  cold  bath.     Hyoscine,  bromide  of  potassium^  or 


CHRONIC   INTERSTITIAL   PNEUMONIA.  225 

chloral  in  small  doses  may  be  required.     In  children  the  fol- 
lowing suppository  is  often  very  efficient : — 

]^  Pulv.  asafcetidse,  3.j ; 

Quininse  sulph.,  gr,  xxx  ; 

01.  theobromatis,  q.s. — M.    (Peppek.) 
Ft.  in  suppop.  No.  xii.     (Child's  size.) 
Sig.— One  every  three  or  four  hours  for  a  child  of  five  years. 

In  delayed  resolution  counter-irritants  should  be  applied  to 
the  aifected  areas,  and  iodide  of  potassium  should  be  adminis- 
tered internally. 

Convalescence  must  be  guarded;  tonics  like  cod-liver-oil, 
iron,  arsenic,  and  hypophosphites  are  useful  restoratives.  A 
change  of  scene  is  desirable. 

CHRONIC  INTERSTITIAL  PNEUMONIA. 

(Cirrhosis  of  the  Lung,    Chronic  Pneumonia,   Pulmonary- 
Induration.  ) 

Definition. — A  chronic  disease  of  the  lung,  characterized 
by  an  overgrowth  of  fibrous  tissue. 

Etiology. — It  is  a  rare  sequel  of  croupous  pneumonia.  It 
is  commonly  found  associated  with  tubercles  in  fibroid  phthisis. 
The  overgrowth  of  connective  tissue  is  sometimes  induced  by 
an  old  fibrinous  pleurisy.  It  may  be  an  expression  of  syphilis. 
It  arises  primarily  from  the  constant  inhalation  of  irritating 
dusts,  as  stone-dust  (Chalicosis),  coal-dust  (Anthracosis), 
metal-dust  (Siderosis). 

Pathology. — When  the  thorax  is  opened  the  lung  is  found 
retracted  and  the  heart  displaced.  The  organ  is  tough,  firm, 
and  more  or  less  airless.  Section  shows  an  overgrowth  of 
fibrous  tissue,  and  usually  inflammation  and  considerable  dila- 
tation of  the  bronchi. 

Symptoms. — Moderate  dyspnoea  and  chronic  cough ;  the 
expectoration  may  be  slight,  but  often  it  is  profuse,  and  fetid 
from  having  been  retained  in  bronchiectatic  cavities.  There 
is  no  fever,  and  the  general  health  may  be  well  preserved  for 
many  years. 

Physical   Signs.  —  Inspection  reveals   retraction   of  the 
affected  side  and  displacement  of  the  apex-beat. 
15 


226  DISEASES   OF   THE   EESPIRATORY   SYSTEM. 

Percussion  often  yields  dulness ;  but  over  saccular  dilata- 
tions of  the  bronchi  there  may  be  hyper-resonance. 

Auscultation.  —  The  vocal  resonance  is  increased  and  the 
breathing  is  often  bronchial  or  cavernous. 

Diagnosis.  Fibroid  Phthisis. — -Involvement  of  both  lungs, 
bacilli  in  the  sputa,  and  fever  would  indicate  fibroid  phthisis. 

Prognosis. — Incurable.  The  duration  is  from  ten  to  twenty 
years. 

Treatment.  —  Palliative.  It  consists  in  good  hygienic 
regulations  and  the  use  of  remedies  directed  to  the  bronchi- 
ectasis. 

GAiPfGRENE  OF  THE  LUNG. 

Definition. — A  putrefactive  necrosis  of  the  lung. 

Etiology. — Gangrene  is  not  a  primary  condition,  but  is 
secondary  to  some  inflammatory  disease  of  the  lung.  It  is  ex- 
cited by  the  entrance  of  bacteria  of  putrefaction,  but  unless  the 
system  is  considerably  reduced  in  vitality  the  tissues,  even 
though  diseased,  show  wonderful  resistance,  and  escape  putre- 
faction. 

Pneumonia,  especially  aspiration-pneumonia,  phthisis,  pres- 
sure of  morbid  growths,  bronchiectasis,  abscess,  and  hemor- 
rhagic infarction  following  embolism  of  the  pulmonary  artery 
are  the  predisposing  pulmonary  conditions ;  and  Bright's  dis- 
ease, alcoholism,  the  infectious  fevers,  and  particularly  diabetes, 
by  lowering  the  vitality,  render  these  conditions  operative. 

Pathology. — The  process  may  be  circumscribed  or  diifiise, 
most  frequently  the  former.  The  affected  part  is  converted 
into  a  greenish-black,  soft  mass,  having  an  extremely  fetid  odor. 
When  the  softened  material  has  been  expectorated  there  is  left 
behind  a  cavity  with  ragged  walls,  containing  a  foul-smelling 
liquid.  The  tissues  around  the  cavity  are  inflamed  and  oede- 
matous. 

Symptoms. — The  symptoms  of  gangrene  are  associated  with 
the  original  disease.  Cough,  dyspnoea,  moderate  fever,  and 
great  prostration  are  generally  present. 

The  expectoration  is  characteristic ;  it  is  profuse,  and  has  a 
penetrating  offensive  odor.     When  allowed  to  stand  in  a  glass 


ABSCESS   OF   THE   LUNG.  227 

vessel  it  separates  into  three  layers  :  a  frothy  layer  on  top,  a 
serous  layer  in  the  middle,  through  which  hang  strings  of  pus, 
and  at  the  bottom  a  layer  of  reddish-green  purulent  material. 
Altered  blood  may  give  it  the  appearance  of  prune-juice. 
Microscopically  it  contains  shreds  of  tissue,  crystals  of 
fatty  acids,  crystals  of  h^ematoidin,  and  numerous  pyogenic 
bacteria. 

Physical  examination  may  reveal  bubbling  rales,  and  later 
cavernous  breathing,  pectoriloquy,  and  localized  tympany  on 
percussion. 

PnoGNOSis. — Grave.  Death  usually  results  from  exhaus- 
tion, but  occasionally  from  hemorrhage  or  pyo-pneumothorax. 

Teeatment. — Nutritious  food,  and  quinine,  strychnia,  and 
alcoholic  stimulants  will  be  required  to  support  the  system. 

The  offensive  odor  of  the  breath  may  be  destroyed  by  car- 
bolic acid  (gr.  j  every  four  hours)  internally,  or  by  inhalations 
of  carbolic  acid  or  creosote.  Turpentine  {^v  every  three 
hours)  has  been  recommended  as  a  stimulant  and  antiseptic. 
When  the  patient's  strength  will  permit,  surgical  interference 
offers  the  best  chance  of  cure. 

ABSCESS  OF  THE  LUNG. 

Definition. — Circumscribed  suppuration  of  the  lung. 

Etiology. — (1)  It  is  rarely  a  sequel  to  pneumonia.  (2) 
Multiple  abscesses  are  often  embolic,  and  result  from  pyaemia. 
(3)  Foreign  bodies  in  the  lungs — something  swallowed  or  an 
hydatid  cyst — may  excite  suppuration.  (4)  External  abscesses 
sometimes  rupture  into  the  lung,  as  an  empyema,  hepatic  ab- 
scess, or  suppurating  mastitis. 

Symptoms. — High  and  irregular  fever,  rigors,  sweats,  and 
jiallor  indicate  suppuration.  Dyspnoea,  cough,  and  purulent 
offensive  sputa  containing  shreds  of  lung  tissue  are  the  pul- 
monary symptoms.  Physical  examination  may  reveal  bub- 
bling rales,  and  later,  cavernous  breathing  and  pectoriloquy. 
Multiple  embolic  abscesses  are  rarely  recognized  during  life. 

Prognosis. — Many  cases  following  pneumonia  and  the 
rupture  of  external  abscesses  into  the  lung  recover.  Embolic 
abscesses  generally  prove  fatal. 


228  DISEASES   OF   THE   EESPIKATORY   SYSTEM. 

Teeatme:nt. — Xutritions  food  aud  quinine,  strychnine,  and 
alcoholic  stimulants  will  be  required  to  support  the  system. 
The  abscess  should  be  opened  and  drained,  as  the  pleural  sac 
is  in  empyema. 

(EDEMA  OF  THE  EUNGS. 

Definitiox. — An  eifusion  of  serous  fluid  into  the  air- 
vesicles  aud  into  the  interstitial  tissue  of  the  luncjs. 

Etiology. — Pulmonary  oedema  is  a  common  cause  of 
death  in  many  acute  and  chronic  diseases  which  end  by  heart- 
failure  and  the  accumulation  of  blood  in  the  lungs. 

It  is  frequently  noted  in  the  course  of  Bright's  disease  and 
cardiac  disease. 

A  local  pulmonary  oedema  is  often  found  around  pulmonic 
consolidations,  abscesses,  and  infarctions. 

PatholoGtY. — The  lungs,  especially  the  dependent  portions, 
are  heavy,  red  in  color,  and  boggy  to  the  feel.  When  the 
affected  portion  is  incised  and  pressure  is  made,  an  abundant 
blood-stained,  frothy  serum  exudes. 

Symptoms. — Extreme  dyspnoea ;  rapid,  labored  breathing  ; 
cough  with  frothy,  blood-stained  expectoration;  cyanosis;  and 
cold  extremities. 

Pkysical  Signs.  Inspection  reveals  evidences  of  dyspnoea — 
sitting  posture  and  prominence  of  the  auxiliary  muscles  of 
respiration. 

Percussion. — Dulness  over  the  bases. 

Auscultation. — Feeble  respiratory  murmur ;  subcrepitant  or 
bubbling  rales. 

Diagnosis.  Pneumonia. — The  absence  of  chill,  of  fever, 
of  "  rusty"  tenacious  sputa,  of  pain,  and  of  signs  indicating 
consolidation  will  indicate  oedema. 

Capillary  Bronchitis. — The  fever  and  muco-purulent  expec- 
toration will  serve  to  distinguish  bronchitis  from  oedema. 

PnoGNOSis. — Always  grave.  It  is  often  a  final  symptom 
of  some  pulmonary  disease.  When  not  advanced,  and  the 
conditions  are  favorable,  recovery  may  follow. 

Treatment. — When  there  is  much  cyanosis,  and  the 
patient's  strength  will  permit  it,  the  application  of  wet  cups 


PULMONARY    COLLAPSE.  229 

to  the  chest  or  bleeding  from  the  arm  is  of  great  value.  Hot 
fomentations  should  be  applied  to  the  chest.  Hydragogue 
cathartics  are  indicated.  Epsom  salts  in  concentrated  solu- 
tions, or  elaterium  (gr.  ^),  may  be  selected.  Cardiac  stimulants 
like  ether,  alcohol,  ammonia,  digitalis,  and  especially  strych- 
nine, are  required,  and  may  be  given  hypodermically. 

^   Strychnin,  sulph.,  gr.  j  ; 
Aquse  destillat.,  f^j. 
Solve  et  sig. — 15  minims  hypodermically  every  three  or  four  hours. 

Caffeine  is  a  useful  diuretic,  and  cardiac  and  respiratory 
stimulant. 

J^:   CafFein.  citratis,  gr.  xl; 
Sodii  benzoat.,  jiss. — M. 
Et.  in  chart.  No.  xii. 
Sig. — One  every  two  or  three  hours 

PULMONARY  COLLAPSE. 

(Atelectasis.) 

Definition — An  absence  of  air  from  a  portion  of  the  lung. 

Etiology, — It  may  be  congenital  and  result  from  deficient 
respiration ;  in  these  cases  the  dependent  portions  of  both 
lungs  are  commonly  affected.  Acquired  atelectasis  results 
from  occlusion  of  a  bronchus  by  a  foreign  body  or  a  plug  of 
mucus,  as  in  capillary  bronchitis ;  or  from  compression  of  the 
lung  by  a  tumor  or  pleural  effusion. 

Symptoms. — When  a  large  area  is  collapsed  in  some  pre- 
existing disease  like  capillary  bronchitis,  there  is  an  abrupt 
increase  in  the  dyspnoea  and  cyanosis,  without  a  corresponding 
rise  of  temperature.  Physical  examination  gives  negative 
results  except  over  extensive  collapse,  which  may  give  dulness 
on  percussion  and  weak  breathing  on  auscultation. 

Prognosis. — This  depends  upon  the  extent  of  collapse  and 
the  gravity  of  the  pre-existing  disease. 

Treatment. — In  congenital  atelectasis  apply  alternately 
hot  and  cold  sponges  to  the  spine ;  keep  up  the  external  tem- 
perature. If  these  measures  fail,  gently  inflate  the  lung  with 
a  catiieter. 

In  the  acquired  varieties   direct  remedies  to  the   original 


230  DISEASES   OF    THE    RESPIRATORY   SYSTEM. 

disease.  Administer  cardiac  and  respiratory  stimulants  like 
ammonia,  strychnine,  and  nitroglycerine.  When  obstruction 
is  due  to  a  plug  of  mucus  an  emetic  is  indicated. 

PULMONARY  TUBERCULOSIS. 

(Phthisis,  Pulmonary  Consumption.) 

Definition. — A  specific  inflammatory  disease  of  the  lungp 
caused  by  the  bacillus  tuberculosis  ;  characterized  anatomicall  y 
by  a  cellular  infiltration  which  subsequently  caseates,  softens, 
and  leads  to  ulceration  of  the  lung  tissue;  and  manifested 
clinically  by  wasting,  exhaustion,  fever,  and  cough. 

Etiology. — (1)  Residence  in  low,  damp,  and  badly-drained 
localities.  (2)  Heredity  (important).  (3)  Age;  all  ages,  but 
especially  between  twenty  and  thirty  years.  (4)  Occupations 
which  necessitate  the  breathing  of  impure  air  and  tlie  inhala- 
tion of  irritating  dusts.  (5)  Catarrhal  inflammation  and 
traumatism  of  the  lungs.  (6)  Physique.  (7)  General  dis- 
eases which  lower  the  vitality,  as  diabetes,  hepatic  cirrhosis, 
and  typhoid  fever. 

The  exciting  cause  is  the  bacillus  tuberculosis,  which  gains 
entrance  (1)  by  direct  parental  transmission  (very  rare)  ;  (2)  by 
inhalation,  the  dust  of  dried  sputum  being  commonly  the 
medium  of  contagion ;  (3)  through  infected  food,  as  the  milk 
and  meat  of  tuberculous  cattle. 

Varieties.  —  (1)  Chronic  ulcerative  phthisis.  (2)  Acute 
phthisis.     (3)  Fibroid  phthisis. 

Pathology. — The  bacillus  tuberculosis  is  a  very  minute 
rod,  about  one-fourth  or  one-half  the  diameter  of  a  red  blood- 
corpuscle,  and  often  slightly  bent  and  beaded.  Its  detection 
depends  on  the  power  of  the  stained  bacillus  to  resist  the  de- 
colorizing effects  of  acids.  For  satisfactory  examination  a 
one-twelfth  oil-immersion  lens  is  required. 

The  lodgment  of  bacilli  in  the  terminal  bronchioles  of  the 
apex  excites  a  proliferation  of  the  fixed  cells,  which  become 
more  or  less  polygonal  in  shape.  The  new  cells  are  termed 
epithelioid,  and  frequently  contain  bacilli.  Giant  cells  are  often 
formed  by  a  fusion  or  overgrowth  of  these  cells. 

This  ao-o-reffation  of  new  cells  acts  as  an  irritant  and  is  soon 


PULMONARY    TUBERCULOSIS.  231 

surrounded  by  a  wall  of  leucocytes,  the  whole  forming  a  gray, 
translucent  mass — the  gray  tubercle  of  Laennec.  In  a  short 
time  the  bacilli  excite  a  coagulation-necrosis  which  starts  in 
the  centre,  spreads  to  the  periphery,  and  converts  the  tubercle 
into  a  yellow,  cheesy  mass — the  yellow  tubercle  of  Laennec. 
The  degenerated  tubercles  fuse  and  form  the  uniform  cheesy 
masses  so  commonly  observed  at  the  autopsy.  At  this  stage 
one  of  two  things  may  occur :  The  mass  may  soften,  break 
into  a  bronchial  tube,  and  leave  behind  a  cavity  with  ulcerat- 
ing walls,  or  it  may  become  encapsulated  by  an  overgrowth  of 
connective  tissue  and  subsequently  calcified.  In  addition  to 
the  specific  process  other  secondary  changes  are  noted.  The 
lung  tissue  in  the  neighborhood  of  the  tuberculous  deposits  is 
often  the  seat  of  a  true  pneumonic  inflammation ;  the  connective 
tissue  is  always  more  or  less  proliferated  ;  the  bronchial  tubes 
are  inflamed  ;  and  the  pleurae  over  the  affected  areas  are  nearly 
always  adherent. 

Chronic  ulcerative  phthisis  usually  begins  at  the  apices. 

Acute  jjhthisis  has  been  tevmed  jihthisis  florida,  cheesy  pneu- 
monia, and  chronic  catarrhal  pneumonia,  but  the  process  is 
invariably  tuberculous.  From  extreme  vuhierability  of  the 
tissues  a  lobe  or  whole  lung,  or  even  both  lungs,  are  rapidly 
infiltrated,  and  death  results  in  from  a  few  weeks  to  a  few 
months. 

In  some  cases  the  lung  is  solidified  by  a  dense  yellowish- 
gray  infiltration  composed  of  closely-aggregated  tubercles ;  in 
others  the  consolidation  appears  in  more  or  less  discrete 
patches  which  have  had  their  origin  in  the  smaller  bronchial 
tubes  ;  in  a  third  form  one  or  both  lungs  are  studded  with  dis- 
crete tubercles,  many  of  which  are  still  gray  and  translucent. 

In  fibroid  phthisis  the  tissues  appear  to  be  resistant,  and 
the  process  is  limited  by  an  overgrowth  of  connective  tissue 
which  forms  dense  bands  around  the  tuberculous  foci.  This 
form  lasts  many  years. 

Chronic  Ulcerative  Phthisis.  Symptoms. — The  onset  is 
usually  insidious  and  marked  by  pallor,  gastric  disturbance, 
loss  of  flesh  and  strength,  and  by  a  dry,  hacking  cough  which 
is  especially  noted  in  the  morning.  From  some  undue  ex- 
posure, the  cough  is  often  aggravated,  and  to  this  obstinate 


232  DISEASES   OF   THE   EESPIEATORY   SYSTEM. 

"cold"  the  disease  is  usually  attributed.  In  some  cases,  the 
symptoms  appear  abruptly  with  hemorrhage  or  an  acute 
pleurisy. 

Slight  fever  and  acceleration  of  the  pulse  are  early  symptoms 
of  great  diagnostic  import.  The  temperature  is  marked  by  an 
evening  exacerbation,  during  which  the  face  is  flushed,  the 
eyes  bright,  and  the  mind  animated.  As  the  disease  ad- 
vances the  cough  becomes  troublesome  and  the  expectoration 
more  abundant.  In  well-developed  cases  the  expectoration  is 
greenish  in  color,  is  in  coin-shaped  plugs  (nummular),  is  heavy 
and  sinks  in  water,  is  often  blood-streaked,  and  on  microscopic 
examination  is  found  to  contain  bacilli  and  fibres  of  elastic 
tissue. 

Phthisis  is  in  itself  not  a  painful  disease,  but  the  associated 
dry  pleurisy  often  causes  much  suffering.  Hsemojitysis  occurs 
at  all  stages,  but  the  profuse  hemorrhages  occur  late.  The 
blood  is  bright  red  in  color,  frothy,  and  mixed  with  mucus. 
Dyspnoea  is  not  a  marked  symptom,  and  its  absence  is  doubt- 
less due  to  the  gradual  development  of  the  disease.  Profuse 
sweating  during  sleep  is  a  troublesome  feature  of  advanced 
phthisis. 

The  final  stage  is  characterized  by  extreme  emaciation, 
weakness,  pallor,  high  remittent  or  intermittent  fever,  and 
oedema  of  the  feet.  The  mind  is  usually  clear,  and  peculiarly 
hopeful  to  the  end. 

Physical  Signs.  Inspection. — The  chest  is  usually  long 
and  flat  ;  the  spaces  above  and  below  the  clavicles  are  sunken  ; 
the  scapulse  are  prominent ;  and  the  ribs  are  oblique. 

There  may  be  flattening  or  less  expansion  over  one  apex. 

Palpation. — Diminished  exj)ansion  and  increased  vocal  fre- 
mitus. 

Percussion. — Dulness,  as  a  rule  ;  this  is  noted  earliest  above 
or  belov/  the  clavicles,  in  the  supraspinous  fossse,  between  the 
scapulae,  or  in  front  near  the  sternal  border. 

A  cavity,  or  vomica,  yields  tympany,  or  a  "  cracked-pot" 
resonance.  The  latter  can  be  more  clearly  demonstrated  when 
the  ear  is  placed  near  the  patient's  open  mouth. 

Auscultation. — In  the  early  stage  respiration  may  be  inaud- 
ible over   the   affected   area.     Later  the  breathing  is  harsh 


PULMONARY   TUBERCULOSIS.  233 

and  the  expiration  prolonged  and  high-pitched  (bronchial). 
The  vocal  resonance  is  increased.  Crackling  rales  are  usually 
audible,  and  are  produced  by  liquid  in  the  small  tubes.  If 
not  present,  coughing  will  usually  develop  them.  Ausculta- 
tion over  cavities  may  detect  cavernous  or  amphoric  breathing, 
pectoriloquy,  and  large  gurgling  rales. 

Anomalous  Physical  Signs. — The  vocal  fremitus  is 
diminished  when  there  is  much  pleural  thickening.  Normal 
resonance  or  hyper-resonance  may  replace  dulness  when  there 
is  much  emphysema  between  small  tuberculous  foci.  Weak 
breathing  may  replace  bronchial  or  cavernous  when  the  tubes 
or  cavity  are  filled  with  muco-pus.  The  signs  of  cavity  are 
sometimes  produced  by  consolidation  in  the  neighborhood  of  a 
large  bronchus. 

Acute  FhtMsiS. — Clinically  this  form  resembles  pneumonia, 
and  is  marked  by  a  chill,  high  fever,  rapid  pulse,  dyspnoea, 
sputum  at  first  rusty  and  then  purulent,  flushed  face,  profuse 
sweats,  and  the  signs  of  consolidation.  Instead  of  ending  by 
crisis  at  the  eighth  or  ninth  day  as  an  ordinary  pneumonia, 
the  symptoms  grow  rapidly  worse,  signs  of  softening  appear, 
the  sputum  shows  bacilli  and  elastic  fibres,  and  death  results 
in  from  a  few  weeks  to  a  few  months. 

Fibroid  PhtMsis. — This  is  a  disease  of  long  duration.  It  is 
characterized  by  very  gradual  loss  of  flesh  and  strength  and 
by  an  abundant  muco-purulent  expectoration,  which  is  at 
times  fetid  from  being  retained  in  dilated  bronchi.  Dyspnoea, 
sweating,  and  fever  are  slight.  There  is  very  marked  retrac- 
tion on  the  affected  side  from  the  shrinking  of  the  fibrous  tis- 
sue ;  with  this  exception  the  physical  signs  are  similar  to  those 
of  ulcerative  phthisis. 

Complications  of  Phthisis. — Haemoptysis ;  pneumonia ; 
pleurisy ;  pneumothorax ;  stomatitis ;  obstinate  vomiting  induced 
by  cough ;  diarrhoea;  amyloid  degeneration  of  the  viscera;  fistula 
in  ano  (tuberculous);  and  secondary  tuberculosis  of  other  organs, 
especially  the  larynx,  cerebral  meninges,  and  peritoneum. 

Diagnosis. — Fever,  cough,  haemoptysis,  night-sweats,  ema- 
ciation, signs  of  consolidation,  and  bacilli  and  elastic  fibres  in 
the  sputum  are  the  diagnostic  phenomena. 


234  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

Prognosis. — Generally  unfavorable,  though  the  disease  is 
not  incurable.  The  accidental  discovery  of  calcified  tubercles 
at  autopsies  furnishes  abundant  evidence  of  spontaneous  cure. 
Many  improve  and  a  few  recover  under  well-directed  treatment. 

A  strong  hereditary  tendency,  a  bad  physique,  high  fever, 
advanced  consolidation,  involvement  of  both  lungs,  even  if 
slight,  unfavorable  surroundings,  and,  it  might  be  added,  a 
slender  purse,  render  the  prognosis  extremely  grave. 

Treatment.  Preventive.  —  Recognizing  the  infectious 
nature  of  the  disease,  the  following  prophylactic  measures 
should  be  observed  :  Sputa  of  consumptives  should  be  received 
in  suitable  vessels  containing  antiseptic  solutions,  and  subse- 
quently destroyed.  Cattle  should  be  rigidly  inspected,  and 
tuberculous  meat,  and  milk  of  tuberculous  cows  declared  un- 
marketable. Phthisical  mothers  should  not  nurse  their  oif- 
spring.  The  healthy  should  not  sleep  in  apartments  occupied 
by  those  affected. 

Personal  Hygiene. — Good  food,  fresh  air,  frequent  bathing, 
avoidance  of  exposure,  graduated  exercise,  residence  in  an 
elevated  locality,  a  diy,  well-ventilated  house,  and  plenty  of 
sleep  and  recreation. 

Curative  Treatment. — This  involves  two  objects :  (1)  The 
strengthening  of  the  patient's  vitality  and  resisting  power. 
(2)  The  destruction  or  disabling  of  the  tubercle  bacilli. 

General  Health. — The  diet  should  be  carefully  regulated. 
Nutrients  like  cod-liver  oil  (5ij — 3iv  two  hours  after  meals), 
malt,  and  hypophosphites  are  often  very  useful.  Mineral  acids 
and  bitters  may  be  required  to  stimulate  digestion.  Iron, 
quinine,  and  arsenic  are  sometimes  indicated  ;  the  last,  when 
well  borne,  often  exerts  a  decidedly  favorable  influence.  Alco- 
hol in  many  cases  is  of  great  value,  but  the  danger  of  inducing 
the  habit  must  be  borne  in  mind.  Beer,  porter,  ale,  and  wine 
are  usually  the  most  desirable  preparations.  So  long  as  alcohol 
stimulates  the  appetite,  lowers  the  temperature,  and  strengthens 
the  pulse  it  does  good.  Its  results  should  be  carefully  noted, 
and  any  untoward  effects  will  call  for  its  immediate  withdrawal. 

Change  of  Climate. — This  offers  to  many  patients  the 
greatest  hope  of  cure.  As  a  rule,  a  high  altitude  should  be 
selected ;  the  atmosphere  should  be  dry  and  the  temperature 


PULMONAEY   TUBERCULOSIS.  235 

equable.  Personal  experience  must  decide  the  question  of 
temperature ;  generally,  patients  who  feel  better  in  summer 
will  do  well  in  a  warm  climate,  and  vice  versa.  The  physician 
should  have  some  knowledge  of  the  locality,  which  should 
afford  ordinary  conveniences,  without  being  too  crowded  with. 
sufferers  similarly  afflicted. 

In  selected  cases,  a  sea  voyage  is  often  very  useful.  Accord- 
ing to  Douglas  Powell,  it  is  most  suitable  to  patients  in  the 
early  stages,  who  have  been  previously  healthy,  who  have 
overworked  nervous  systems,  and  in  whom  the  disease  is 
more  or  less  quiescent. 

Specific  Treatment. — The  injection  of  iodine,  carbolic  acid, 
etc.  into  phthisical  lungs,  as  recommended  by  Mosler,  Thomp- 
son, and  Pepper,  has  not  given  encouraging  results.  Koch's 
tuberculin  has  been  shown  to  be  either  negative  or  deleterious 
in  its  effects.  Of  the  special  remedies  which  have  been  recom- 
mended, creosote  or  one  of  its  derivatives  alone  holds  a  prom- 
inent position  in  the  therapy  of  phthisis.  It  may  be  given  in 
pill,  in  emulsion  of  cod-liver  oil,  or  with  wine. 

]^   Creosoti,  TTLxv  ; 
Olei  morrhuse,  f^iij  ; 
Calcii  et  sodii  hyposphos.,  gss; 
Olei  gaultheriee,  TTLxx ; 
Acaciae,  q,  s. 
Aquse,  q.  s.  ad  f.lvj.  — M. 
Sig. — A  tablespoonful  two  hours  after  meals. 

The  carbonate  of  guaiacol,  being  odorless  and  tasteless,  and 
less  irritating  than  creosote,  is  preferable  to  the  latter.  The 
daily  dose  is  15  to  60  grains. 

R    Strychnin,  sulph.,  gr.  ss  ; 

Codein.,  gr.  v ; 

Guaiacol  carbonat.,  gr.  c. — M. 
Pone  in  capsulas  No.  xx. 
Sig. — One  every  three  hours. 

Creosote  is  often  valuable  in  inhalations. 

^   Creosoti, 

Spt.  chloroform i. 
Alcoholis,  aa  f^ss. — M. 
Sig. — Ten  to  twenty  drops  in  the  inhaler  several  times  daily. 


236  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

Symptomatic  Treatment.  Cough. — Syrups  should  be  avoided 
as  far  as  possible,  and  cough  alleviated  -by  inhalations  of  wine 
of  ipecac,  creosote,  benzoin,  or  terebene. 

Tar,  terebene,  and  eucalyptus  may  be  employed  internally. 
Cough  associated  with  the  expectoration  of  much  oflensive 
material  should  not  be  checked. 

A  cold  bed  often  leads  to  cough  and  a  wakeful  night ;  in 
these  cases  the  bed  should  be  warmed  before  it  is  occupied. 
Hot  applications  to  the  chest  and  a  hot  drink  on  retiring 
sometimes  insure  rest. 

The  following  mixture  is  very  efficient  in  the  cough  of 
phthisis : — 

^   Codeinee  sulph.,  gr.  iv  ; 

Acid,  livdrocvanic.  dil.,  TTL^sxij  ; 
Syr.  tola.,  fgij.— M.     (Da  Costa.) 

Sig.  — A  teaspoonful  three  or  four  times  daily. 

Sweating.— Xivo^me  (gr.  jIq),  picrotoxin  (gr-^^Q-sV)'  g^^^^c 
acid  (gr.  x),  camphoric  acid  (gr.  xx-xxx),  agariein  (gr.  ^r-l).     . 

^  Atropiu.  sulpli.,  gr.  I; 
Acid,  sulph.  aroniat.,  fSij  ; 
Aquie  rosfe,  q.  s.  ad  ff  j. — M. 
Sig. — Twenty  to  thirty  drops  at  bedtime,  and  repeated  if  neces- 
sary. 

Sponging  with  alum  and  whiskey  is  sometimes  very  efficacious. 

Hmmoptysis. — When  profuse,  ice  may  be  held  in  the  mouth 
and  swallowed  slowly.  The  fluid  extract  of  ergot  (gtt.  xx- 
xxx)  and  morphine  (g.  \)  should  be  given  hypodermically. 
The  interual  administration  of  gallic  acid  and  other  astrin- 
gents is  of  little  value.  The  application  of  a  temporary  liga- 
ture to  one  or  more  of  the  members  hinders  the  flow  of  blood 
in  the  veins,  and  may  materially  aid  in  checking  the  bleeding. 

When  the  hemorrhage  is  more  or  less  continuous,  but  not 
profuse,  the  fluid  extract  of  hamamelis  (3ij-5iij)  or  pills  of 
acetate  of  lead  and  opium  are  efficient  remedies. 

Biarrhcea. — Rest ;  liquid  diet ;  subnitrate  of  bismuth  in 
large  doses,  or  pills  of  nitrate  of  silver  and  opium. 

^   Bismuth,  subnit.,  gvj  ; 

Salol,  gr.  xxiv  ; 

Morphin,  sulph.,  gr.  j. — M. 
Ft.  in  chart.  Xo.  xii. 
Sig. — One  powder  every  three  hours. 


PLEURISY.  237 

Pyrexia. — Rest  is  imperative.  Quinine  or  autipyrin,  or 
sponging  with  alcohol  and  cool  water,  may  prove  useful. 
Guaiacol  (10-20  drops)  applied  externally  has  been  advo- 
cated, but  its  use  is  often  followed  by  chills,  sweating,  and 
even  collapse. 

Pain. — The  pleuritic  pains  may  be  relieved  by  opium  and 
the  application  of  adhesive  strips,  dry  cups,  or  iodine. 

PLEURISY. 

(Pleuritis.) 

Definition. — Inflammation  of  the  pleura. 

Varieties. — According  to  cause,  it  may  be  divided  into 
primary  or  secondary ;  according  to  extent,  into  unilateral, 
bilateral,  or  local ;  according  to  time,  into  acute  or  chronic ; 
and  according  to  the  exudation,  into  sero-fibrinous,  fibrinous, 
or  purulent. 

Etiology. — Pleurisy  may  be  :  (1)  Idiopathic,  arising  from 
exposure  to  cold  and  wet.  (2)  Traumatic.  (3)  Secondary  to 
inflammatory  diseases  of  adjacent  viscera,  as  pneumonia  and 
phthisis.  (4)  Secondary  to  some  general  morbid  process,  as 
rheumatism,  Bright's  disease,  tuberculosis,  and  the  infectious 
fevers.     (5)  Tuberculous.     (6)  Cancerous  (rare). 

Pathology. — In  the  early  stage  the  membrane  is  red, 
sticky,  lustreless,  and  covered  with  a  thin  film  of  lymph  ;  if 
the  process  now  ceases,  the  condition  is  termed  dry  pleurisy. 
If,  however,  the  inflammation  continues,  an  exudate  is  formed 
which  may  be:  (1)  Sero-fibrinous,  (2)  fibrinous,  or  (3)  puru- 
lent (empyema).  In  the  sero-fibrinous  form  there  is  little 
lymph,  the  exudate  being  mainly  composed  of  straw-colored 
serum  (a  few  ounces  to  several  pints)  which  in  favorable 
cases  is  gradually  absorbed.  In  large  effusions  the  adjacent 
organs  are  displaced  and  the  lungs  are  compressed.  In  the 
fibrinous  form  serum  is  scant  and  the  membrane  is  cov- 
ered with  a  butter-like  exudate  which  subsequently  organizes 
and  unites  more  or  less  closely  the  pleural  surfaces,  causing 
adhesive  pleurisy,  A  liquid  effusion,  which  is  circumscribed 
and  confined  to  pockets  formed  of  adhesions,  is  termed  saccur- 
lated  pleurisy. 


238  DISEASES   OF   THE   EESPIRATOEY   SYSTEM. 

In  the  purulent  form  the  sac  is  more  or  less  filled  with 
greeuish-yellow  pus.  Purulent  pleurisy,  or  empyema,  is  com- 
mon in  children ;  it  frequently  follows  the  infectious  fevers  ; 
it  is  often  secondary  to  a  sero-fibrinous  pleurisy  ;  it  results 
from  the  rupture  of  purulent  accumulations  into  the  pleura, 
as  by  a  tuberculous  cavity ;  and  finally,  it  may  be  due  to 
traumatism,  as  a  penetrating  wound  or  fracture  of  the  ribs. 

A  purulent  effusion  left  to  itself  may  kill  by  sepsis,  may 
become  inspissated  and  encysted  (rare),  or  may  perforate  into 
the  bronchi,  into  neighboring  organs,  or  externally. 

Hemorrhagic  Pleurisy. — A  bloody  effusion  is  observed  in 
tuberculous  and  cancerous  pleurisies  and  in  pleurisy  which  is 
associated  with  scurvy,  grave  aneemia,  and  other  cachectic 
states. 

An  effusion  of  any  kind  remaining  unabsorbed  constitutes  a 
chronie  pleurisy. 

Symptoms.  Acute  Pleurisy. — The  disease  usually  begins 
abruptly  with  a  sharp,  stabbing  pain  in  the  side  and  moderate 
fever  (102°-103°).  In  some  instances  these  symptoms  are 
preceded  by  a  chill.  Cough  appears  early ;  it  is  usually  dry, 
and,  on  account  of  the  pain,  it  is  partially  suppressed.  As 
the  effusion  accumulates  and  the  inflamed  surfaces  separate, 
the  pain  diminishes,  but  dyspnoea  and  cyanosis  rapidly  de- 
velop. 

Physical  Signs.  First  Stage.  —  Less  expansion  on  the 
affected  side  on  account  of  the  pain  ;  occasionally  a  friction- 
fremitus  on  palpation,  and  a  harsh  to-and-fro  friction-rub  on 
auscultation. 

Stage  of  Effusion.  Inspection. — Immobility  and  bulging  of 
the  intercostal  spaces  on  the  affected  side.  The  apex-beat  is 
displaced  upwards,  and  to  the  left  or  right  according  to  the 
pleura  affected. 

Palpation. — Immobility  and  diminished  vocal  fremitus. 

Percussion. — Dulness  gradually  rising  as  the  fluid  increases. 
The  upper  line  of  dulness  is  not  horizontal,  but  is  curved  and 
rises  higher  posteriorly.  In  moderate  effusions  the  level  of 
dulness  often  changes  with  the  position  of  the  patient.  Above 
the  effusion  percussion  gives  a  tympanitic  note  which  has  been 
termed  Skoda's  resonance. 


PLEUEISY.  239 

Ausoultation. — The  respiratory  sounds  are  weak  and  dis- 
tant ;  they  may  have  a  tubular  or  bronchial  quality.  The 
vocal  resonance  is  usually  diminished  or  absent,  but  occa- 
sionally bronchophony,  or  its  modification  segophony  (a  bleating 
sound),  is  heard  over  moderate  effusions. 

Mensuration. — The  affected  side  is  sometimes  an  inch  or 
more  larger  than  the  sound  one. 

After  absorption  of  the  effusion  the  friction-sound  returns. 

Diagnosis.  Pneumonia. — The  severe  chill,  rusty  expec- 
toration, high  fever,  marked  dyspnoea,  the  fine  crepitant  rales 
which  are  heard  only  on  inspiration,  dulness  not  changing  with 
the  patient's  posture,  increased  vocal  fremitus,  increased  vocal 
resonance,  loud  bronchial  breathing,  and  the  absence  of  bulg- 
ing and  of  a  displaced  apex-beat,  will  serve  to  distinguish  it 
from  pleurisy. 

Pleurodynia,  or  Rheumatism  of  the  Intercostal  Muscles.- — No 
fever,  much  diffuse  tenderness,  no  friction-sounds,  and  no 
effusion. 

Purulent  pleurisy  is  recognized  by  hectic  symptoms — high 
and  irregular  fever,  sweats,  chills,  and  anaemia ;  by  the  results 
of  aspiration  ;  and  sometimes  by  "  pitting"  from  oedema  of  the 
surface. 

Fibrinous  Pleurisy. — Pain  is  severe  and  continuous,  the 
dulness  is  immobile,  aspiration  gives  negative  results,  and  later 
there  is  much  retraction  of  the  affected  side. 

Tuberculous  Pleurisy. — Tuberculosis  is  the  most  common 
cause  of  pleurisy  which  is  apparently  primary.  It  may  be 
primary  or  secondary  to  pulmonary  phthisis.  It  usually  pre- 
sents the  same  symptoms  as  ordinary  sero-fibrinous  pleurisy, 
but  it  often  develops  insidiously,  is  frequently  bilateral,  and 
the  effusion  is  apt  to  be  bloody.  These  facts,  together  with 
the  history,  will  usually  indicate  the  diagnosis. 

Hydrothorax. — In  this  condition  pain,  fever,  and  friction- 
sounds  are  absent.  The  effusion  is  more  apt  to  be  bilateral. 
There  is  often  a  history  of  cardiac  or  renal  disease,  and  the 
fluid  on  aspiration  is  found  to  contain  less  than  3  per  cent,  of 
albumin,  and  to  have  a  specific  gravity  below  1.015. 

Diaphragmatic  pleurisy,  or  inflammation  of  the  diaphrag- 
matic pleura,  may  present  the  following  symptoms  :  Intense 


240  DISEASES    OF    THE    EESPIRATOKY    SYSTEM. 

pain  under  the  margin  of  the  ribs,  with  tenderness  on  press- 
ure ;  thoracic  breathing ;  tenderness  over  the  phrenic  nerve, 
which  is  accessible  between  the  two  roots  of  the  sterno-cleido- 
mastoid  at  the  base  of  the  neck  ;  hiccough ;  and  extreme 
dyspnoea.     The  physical  signs  are  not  marked. 

Prognosis. — This  depends  largely  on  the  character  and 
the  amount  of  effusion.  In  primary  sero-fibrinous  pleurisy, 
the  prognosis  is  usually  good,  but  that  pleurisies,  which  are 
apparently  primary,  are  often  tuberculous,  should  always  be 
borne  in  mind.  In  purulent  pleurisy,  the  prognosis  is  grave, 
though  recovery  frequently  occurs. 

In  the  fibrinous  form,  the  prognosis  is  good,  but  if  there 
has  been  much  exudate,  subsequent  retraction  and  more  or 
less  impairment  of  the  affected  side  are  sure  to  follow. 

Treatment. — Absolute  rest.  Light  diet.  If  the  temper- 
ature is  high  and  the  pulse  rapid,  aconite  may  be  administered 
in  small  doses.  Quinine  (gr.  v  thrice  daily)  will  exert  a  favor- 
able influence.  Pain  may  be  so  severe  as  to  require  morphia 
hypodermically. 

Local  Applications. — When  the  pain  is  severe,  leeches  or 
wet-cups,  followed  by  strapping  of  the  chest,  will  give  great 
relief.  In  other  cases,  mustard  plasters,  hot  fomentations,  or 
iodine  may  be  applied. 

Serous  Effusion. — Apply,  frequently,  small  blisters.  Iodide 
of  potassium  (gr.  v  thrice  daily)  may  be  employed  for  its  ab- 
sorbent effect. 

Encourage  diuresis  with  digitalis,  caffeine,  or  acetate  of 
potassium : — 

T^  Potass,  acetat.,  §ss  ; 

Infus.  digitalis,  f  §iij. — M. 
Sig. — Two  teaspooufuls  every  three  or  four  hours. 

Encourage  catharsis  with  compound  jalap  powder  (gr.  xx- 
xxx)  Or  Epsorn  salts. 

^  Magnesii  sulphat.,  iiv-§vj. 
Div.  in  chart.  No.  viii. 

Sig. — One  powder  in  two  tablespoonfuls  of  water  before  food,  and 
no  fluids  for  some  time  afterwards. 

The  effusion  will   require  aspiration  under   the    following 


HYDROTHORAX — PNEUMOTHORAX.  241 

conditions :  (1)  When  it  excites  much  dyspnoea ;  (2)  \vhen  it 
is  very  large,  beyond  the  third  or  fourth  rib ;  (3)  when  it  is 
purulent;  (4)  when  it  remains  unabsorbed  after  three  or  four 
w^eks  of  careful  treatment ;  (5)  when  it  is  bilateral,  and  the 
total  amount  is  sufficient  to  fill  one  cavity. 

The  Operation. — Anaesthetize  a  point  in  the  seventh  inter- 
space near  the  posterior  axillary  line  and  introduce  the  needle 
with  a  quick  stroke  along  the  upper  border  of  the  rib.  The 
effusion  should  be  drawn  off  slowly,  and  one  or  two  pints  re- 
moved according  to  the  amount  of  the  exudate. 

Coughing  during  the  operation  is  an  indication  for  the  with- 
drawal of  the  needle. 

HYDROTHORAX. 

Definition. — Thoracic  dropsy. 

Etiology. — -It  is  always  secondary,  and  may  result  from 
one  of  the  causes  of  general  dropsy,  namely  :  Bright's  disease, 
heart  disease,  emphysema  or  anaemia,  or  from  the  pressure  of 
a  tumor  or  aneurism  upon  the  thoracic  veins. 

Symptoms. — Dyspnoea,  cyanosis,  and  the  physical  signs  of 
a  pleural  effusion. 

Diagnosis.  Pulmonary  Oedema. — The  upper  level  of 
dulness  is  not  movable ;  the  intercostal  spaces  are  not  unduly 
prominent ;  the  apex-beat  is  not  displaced ;  and  auscultation 
reveals  abundant  moist  rales. 

Treatment. — Remedies  should  be  directed  to  the  original 
disease.     When  there  is  much  dyspnoea,  aspirate. 

PNEUMOTHORAX. 

Definition. — Air  in  the  pleural  sac. 

Etiology. — It  may  result  from  :  (1)  The  rupture  of  the 
lung  in  health  from  a  violent  strain,  or  rupture  in  tuberculosis, 
abscess,  emphysema,  or  gangrene.  (2)  Traumatism,  as  a  pen- 
etrating wound  or  a  fracture  of  the  ribs.  (3)  The  rupture  of 
an  empyema  into  the  lung. 

Pathology. — The  adjacent  viscera  are  displacedj  and  the 
16 


242  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

lung  is  compressed.  Even  when  air  alone  has  escaped  into 
the  pleural  sac  an  effusion  soon  develops,  so  that  in  all  cases 
.the  condition  becomes  a  pneumo-hydrothorax  or  -jpyotliorax. 

Symptoms. — The  onset  is  marked  by  a  sharp  pain,  extreme 
dyspnoea,  cyanosis,  and  symptoms  of  incipient  collapse,  namely, 
a  fall  of  temperature,  a  weak  rapid  pulse,  cold  extremities,  and 
pinched  features. 

Physical  Signs.  Inspection. — Immobility,  and  bulging 
of  the  intercostal  spaces.     The  apex-beat  is  usually  displaced. 

Palpation. — Diminished  vocal  fremitus. 

Percusdon. — A  tympanitic  note,  varying  in  pitch  with  the 
intrathoracic  tension. 

Effusion  sinks  to  the  base  and  yields  dulness,  the  outline  of 
which  changes  with  the  position  of  the  patient. 

Auscultation. — The  respiratory  murmur  and  vocal  resonance 
are  usually  absent,  but  when  the  opening  in  the  lung  remains 
patulous,  amphoric  breathing  may  be  detected.  When  a  silver 
coin  is  placed  on  the  affected  side  and  is  struck  with  another, 
the  auscultator  detects  a  clear  metallic  sound  (bell-tympany). 
When  fluid  is  present,  shaking  the  patient  excites  a  splashing 
sound  (Hippocratic  succussion). 

Diagnosis.  A  large  Phthisical  Cavity. — This  is  usually 
located  near  the  apex  instead  of  the  base ;  the  surface  is 
sunken,  not  prominent ;  the  heart  is  not  displaced ;  succus- 
sion-splash  and  bell-tympany  are  usually  absent. 

Dilated  Stomach. — This  may  give  a  tympanitic  note  over 
the  left  pulmonary  base,  and  may  simulate  a  pneumothorax ; 
but  the  tympanitic  note  is  continued  down  into  the  abdomen, 
and  the  swallowing  of  liquid  is  distinctly  audible  over  the 
base  of  the  chest. 

Prognosis. — It  is  usually  unfavorable,  and  often  termi- 
nates fatally  in  a  few  hours  or  days.  Recovery  is  possible, 
especially  in  traumatic  cases.  It  often  excites  a  pleural  effu- 
sion and  runs  a  chronic  course. 

Treatment. — At  the  onset  administer  stimulants,  and  apply 
straps  to  the  chest.  The  pain  and  distress  must  be  relieved  by 
morphine.  When  effusion  forms  it  should  be  treated,  accord- 
ing to  its  character,  as  a  serous  or  a  purulent  pleurisy. 


H^MOTHOEAX.  243 

HEMOTHORAX. 

(Hsematothorax. ) 

Definition. — The  effusion  of  blood  into  the  pleural  sac. 

Etiology. — Traumatism,  rupture  of  an  aneurism,  or  the 
erosion  of  bloodvessels  by  cavities  or  caries  of  the  ribs. 

Symptoms. — Same  as  hydrothorax. 

Treatment. — When  there  is  great  dyspnoea  the  blood 
should  be  removed  by  aspiration  or  incision. 

PYOTHORAX. 

(Empyema.) 

Definition. — An  effusion  of  pus  into  the  pleural  sac. 

Etiology. —  (1)  The  effusion  may  be  primarily  purulent, 
the  inflammation  having  been  excited  by  pyogenic  microor- 
ganisms. (2)  A  sero-fibrinous  pleurisy,  through  subsequent 
infection,  may  be  converted  into  an  empyema.  The  predis- 
posing causes  are  much  the  same  as  those  of  sero-fibrinous 
pleurisy.  Traumatism  or  the  rupture  of  a  purulent  accumu- 
lation into  the  pleural  sac  is  an  occasional  cause.  It  frequently 
follows  pneumonia,  particularly  in  children,  in  whom  the  most 
common  form  of  pleurisy  is  empyema.  It  is  often  secondary 
to  tuberculosis  or  one  of  the  infectious  fevers. 

Streptococci,  pneumococci,  tubercle  bacilli,  Eberth's  bacilli, 
and  staphylococci  are  capable  of  exciting  empyema. 

Symptoms. — The  physical  signs  and  symptoms  are  similar 
to  those  observed  in  sero-fibrinous  pleurisy.  Pus  is  indicated 
by  hectic  phenomena — high  and  irregular  fever,  sweats,  chills, 
and  anaemia;  by  the  results  of  aspiration;  and  sometimes  by 
oedema  of  the  chest-walls.  In  pulsating  pleurisy  the  effusion 
is  almost  always  purulent. 

Prognosis. — Grave,  though  recovery  frequently  occurs. 
The  most  favorable  cases  are  those  following  pneumonia. 

Treatment. — Free  incision  and  thorough  drainage.  Irri- 
gation is  unnecessary  unless  the  fluid  is  putrid.  In  long-stand- 
ing cases  the  excision  of  several  ribs  (Estlander's  operation) 
facilitates  retraction  and  the  obliteration  of  the  pleural  sac, 
which  is  essential  to  a  cure. 


ACUTE  INFECTIOUS  DISEASES. 


FEVEK. 


Fever  is  an  abnormal  condition  characterized  by  elevated 
temperature,  quickened  respiration  and  circulation,  faulty  se- 
cretions, and  increased  tissue-waste  ;  and  dependent  upon  a 
perversion  of  the  physiological  processes  whereby  the  gene 
ration  and  loss  of  heat  are  so  balanced  as  to  maintain  a  uni 
form  normal  temperature. 

The  Detection  of  Fever. — There  is  only  one  sure  way  of 
detecting  fever,  and  that  is  by  means  of  the  clinical  ther- 
mometer. The  instrument  may  be  placed  in  the  axilla, 
mouth,  rectum,  or  vagina. 

When  the  axilla  is  selected  the  following  precautions  must 
be  observed  :  Wipe  off  the  perspiration  and  dry  the  skin  ;  in- 
sert the  bulb  of  the  instrument  deep  in  the  armpit,  and  see 
that  the  arm  is  kept  close  to  the  side.  The  thermometer 
should  be  kept  in  position  until  the  mercury  maintains  the 
same  level  for  two  minutes  ;  this  will  usually  require  in  aP 
about  six  or  seven  minutes. 

When  the  mouth  is  selected  the  bulb  should  be  placec 
under  the  tongue  and  the  lips  kept  closed.  Hot  and  cok 
drinks  recently  taken  mar  the  results.  For  obvious  reason 
the  mouth  should  not  be  used  in  delirious  patients. 

The  rectum  may  be  selected  in  children.  The  rectal  tem- 
perature is  about  a  degree  higher  than  that  of  the  axilla. 

Febrile  Stages.— The  course  of  all  fevers  is  marked  by  thn 
stages:    (1)  Invasion;  (2)  fastigium,  or   stadium;   (3)  defer- 
vescence   or  dechne. 

Invasion.— Dwx'mg  this  period  the  temperature  gradually 
rises  until  it  reaches  its  maximum. 
(244) 


FEVER.  245 

Fasiigium. — In  this  period,  though  there  may  be  marked 
variations,  the  temperature  shows  a  tendency  to  touch  again 
and  again  its  highest  point. 

Defervescence. — In  this  period  the  temperature  gradually 
falls  until  it  reaches  the  norm. 

Terminations  of  Fever.  —  Fever  terminates  by  lysis  or 
crisis. 

Lysis. — The  temperature  falls  slowly  by  slight  gradations 
until  it  reaches  the  norm. 

Crisis. — The  temperature  falls  suddenly,  often  four  or  five 
degrees  in  twelve  or  twenty-four  hours. 

The  Degree  of  Pyrexia. — The  following  is  Wunderlich's 
classification  of  febrile  temperatures  : — 

1.  Subfebrile,  temperature  99.5°-100.4°. 

2.  Slightly  febrile,  temperature  100.4°-101.3°. 

3.  Moderately  febrile,  temperature  101. 3°-l 03.1°. 

4.  Decidedly  "Afebrile,  temperature  103.1  °-104°. 

5.  Highly  febrile,  temperature  above  103.1°  in  the  morning 

and  above  104.9°  in  the  evening. 

6.  Hyperpyretic,  temperature  above  106°. 

Febrile  Remissions. — All  fevers  show  a  diurnal  variation. 
The  maximum  is  usually  reached  at  about  6  P.M.  and  the 
minimum  at  about  6  A.M.  Sometimes  these  extremes  are  re- 
versed and  the  maximum  is  in  the  morning  and  the  minimum 
in  the  evening.     The  daily  difference  amounts  to  about  1°. 

Types  of  Fever. — According  to  the  degree  of  the  diurnal 
variation  three  types  are  recognized  : — 

1.  Continued  Fever. — The  diurnal  variation  is  slight,  1°— 1.5°. 
Typhus  fever,  pneumonia,  and  scarlet  fever  are  examples  of 
continued  fevers. 

2.  Remittent  Fever. — The  diurnal  variation  is  marked,  but 
the  minimum  temperature  is  still  above  the  norm.  Typhoid 
fever,  remittent  fever,  and  hectic  fever  are  examples  of  this 

3.  Intermittent  Fever. — The  diurnal  variation  is  marked,  and 
the  minimum  is  normal  or  subnormal.  The  following  fevers 
intermit  : — 


246  ACUTE   INFECTIOUS   DISEASES. 

1.  Intermittent  fever  (malaria). 

2.  Relapsing  fever. 

3.  Hectic  fever  (often  intermits,  though  generally  remits). 

4.  Charcot's  intermittent  (the  peculiar  fever  associated  with 

the  impaction  of  gall-stones). 

Causes  of  Fever.  —  (1)  Local  inflammations  excited  by 
external  causes,  or  the  products  of  faulty  metabolism 
(gout,  rheumatism).  (2)  The  presence  in  the  body  of  micro- 
organisms, or  of  toxines  produced  by  them,  as  in  typhoid 
fever,  pyaemia,  scarlet  fever,  etc.  (3)  Paralysis  of  the  heat- 
centre,  as  in  thermic  fever. 

Symptoms  of  Fever. — Rise  of  temperature;  rapid  pulse; 
rapid  respirations ;  coated  tongue ;  anorexia ;  constipation. 
Tlie  urine  is  scanty,  high-colored,  throws  down  a  heavy  sedi- 
ment, and  may  contain  a  trace  of  albumin.  The  gastric  juice 
is  deficient  in  acid.  If  the  fever  is  long-continued,  the  body 
wastes. 

The  Pulse-temperature  ratio : — 

A  temperature  of    98.4°  corresponds  to  a  pulse  of  70 

u               u     100°              "            "        "  80-  90 

a           -    u     102°              "            "         "  100-110 

«               "     104°              "             "         "  120-130 

Effects  of  Fever  on  the  Tissues. — High  and  long-continued 
fever  produces  fatty  and  parenchymatous  degeneration  of  the 
tissues. 

Treatment  of  Fever. — Absolute  rest ;  a  cool,  well- ventilated 
room  ;  liquid  or  semi-liquid  diet.  Slight  fever  will  require  no 
special  remedies,  but  the  patient  may  be  made  more  comfort- 
able by  sponging  with  cool  water,  or  water  and  alcohol ;  and 
by  the  use  of  such  drugs  as  sweet  spirits  of  nitre,  acetate  of 
ammonium,  or  neutral  mixture. 

High  fever  is  best  controlled  by  the  external  application 
of  cold  ;  this  method  includes  sponging  with  cold  water,  the 
cold  pack,  and  the  cold  bath. 

The  Cold  Pack. — A  rubber  sheet  is  slipped  under  the  patient, 
and  the  body  is  enveloped  in  a  sheet  wrung  out  in  cold  water, 


FEVER.  247 

which  is  allowed  to  remain  antil  the  temperature  falls  one  or 
two  degrees. 

The  Cold  Bath. — There  are  two  methods  of  administering 
the  cold  bath.  The  first  is  to  place  the  patient  at  once  into 
water  at  70° ;  the  other  is  to  place  him  into  water  at  90°  or 
80°,  and  then  gradually  cool  it  down  to  75°  or  70°.  While  in 
the  water  an  ice-bag  is  kept  upon  his  head,  and  his  body  is 
subjected  to  vigorous  rubbing.  He  should  remain  in  the 
bath  for  fifteen  or  twenty  minutes,  after  which  he  should  be 
placed  in  a  dry  sheet  and  covered  with  a  light  blanket. 
When  the  body  is  dry  the  damp  sheet  should  be  removed. 
A  stimulant  is  sometimes  required  during  or  after  the  bath. 

Drugs  may  be  employed  to  lower  temperature,  but  the  bath 
is  preferable  when  it  is  feasible.  Quinine,  antipyrin,  phe- 
nacetiu,  and  acetanilid  are  the  antipyretics  most  commonly 
employed. 

Period  of  Incubation, — The  period  elapsing  between  the  en- 
trance of  the  poison  and  the  development  of  symptoms. 

It  varies  considerably  in  the  same  disease,  being  more  or  less 
influenced  by  the  susceptibility  of  the  patient  and  the  virulence 
of  the  contagion.  The  average  period  of  incubation  in  the  in- 
fectious fevers  is  as  follows  : — 

Typhoid  fever:  two  to  three  weeks. 

Typhus  fever:  a  few  hours  to  two  weeks. 

Measles:  two  weeks. 

Eotheln  or  rubella:  ten  to  twelve  days. 

Scarlatina :  a  iew  hours  to  a  week. 

Smallpox :  one  to  two  weeks. 

Erysipelas :  three  to  seven  days. 

Diphtheria :  two  to  ten  days. 

Varicella :  ten  ta  fifteen  days. 

Tetanus :  a  few  days  to  two  weeks. 

Mumps:  two  to  three  weeks. 

Yellow  fever :  from  a  few  hours  to  a  week. 

The  date  at  which  rashes  appear  in  the  various  diseases:— 

Typhoid  fever:  seventh  to  the  ninth  day. 
Typhus  fever:  fourth  or  fifth  day. 


248  ACUTE  INFECTIOUS   DISEASES. 

Smallpox :  third  or  fourth  day. 
Measles:  third  or  fourth  day. 
Scarlatiua:  first  or  second  day. 
Rotheln  or  rubella:  first  or  second  day. 
Varicella :  first  day. 

Protection  from  Future  Attacks. — Few  diseases  give  abso- 
lute immunity  from  future  attacks,  but  the  following  are  fairly 
protective : — 

Typhoid  fever:  relapses  are  common,  and  second  attacks  some- 
times occur. 

Typhus  fever :  second  attacks  very  rare. 

Measles :  second  attacks  uncommon  ;  what  is  supposed  to  be  a 
second  attack  is  usually  rotheln. 

Rotheln :  second  attacks  uncommon. 

Scarlatina :  second  attacks  rare. 

Smallpox :  second  attacks  occasionally  occur. 

Mumps :  second  attacks  rare. 

Yellow  fever:  second  attacks  rare. 

The  following  do  not  confer  immunity  : — 

Erysipelas.  Malaria. 

Relapsing  fever.  Influenza. 

Diphtheria.  Croupous  pneumonia. 

Periodic  Remission  or.  Intermissions  in  the  Fever. — Such 
remissions  or  intermissions  occur  in  the  following  fevers  : — 

Malarial  fever:  every  day,  every  third  day,  or  every  fourth 

day,  according  to  the  type. 
Relapsing  fever  :  intermissions  occur  at  intervals  of  five  or  six 

days,  and  last  five  or  six  days. 
Smallpox :  remission  occurs  on  the  third  day. 
Measles:  a  distinct  remission  often  occurs  on  the  second  or 

third  day. 
Yellow  fever :  a  marked  remission  on  the  third  or  fourth 

day. 
Dengue :  a    marked  remission  on  the  third  or  fourth  day, 

which  lasts  two  or  three  days. 


SUBNORMAL  TEMPERATURE.  249 

The  Infectious  Fevers  which  at-e  usually  Associated 
with  Jaundice: — 

Yellow  fever. 

Relapsing  fever. 

Acute  yellow  atrophy  of  the  liver. 

Bilious  remittent  fever. 

Termination  by  Crisis. — The  following  infectious  fevers  are 
apt  to  end  by  crisis  : — 

Typhus  fever.  Measles. 

Pneumonia.  Relapsing  fever. 

Influenza.  Erysipelas. 

SUBIN^ORMAL  TEIVIPERATURE. 

Temperatures  below  97.5°  may  be  considered  subnormal. 
They  are  observed  in  the  following  conditions  : — 

1.  During  convalescence  from  certain  febrile  diseases;  after 
pneumonia  and  typhoid  fever  the  temperature  may  remain 
subnormal  for  several  days. 

2.  In  collapse.  This  may  result  from  shock  ;  from  hemor- 
rhage ;  from  the  action  of  some  toxic  agent ;  from  simple  heart- 
failure  in  the  course  of  disease ;  or  from  the  rupture  of  a  viscus, 
as  the  bowel  in  typhoid,  the  lung  in  phthisis,  or  the  stomach  in 
perforating  ulcer. 

3.  In  cholera.  In  this  disease  the  temperature  may  be  very 
low  (90°-85°)  for  several  days. 

4.  In  certain  chronic  diseases,  especially  myxcedema,  dia- 
betes, cancer,  chronic  cardiac,  cerebral,  and  spinal  diseases. 


250  ACUTE  INFECTIOUS   DISEASES. 

SIMPLE  CONTINUED  FEVER. 

(Febricula,  Ephemeral  Fever.) 

Definition. — An  acute  febrile  disease,  of  short  duration, 
and  not  excited  by  a  special  poison. 

Etiology. — It  is  generally  met  with  in  young  and  sensi- 
tive individuals.  Exposure  to  the  sun,  prolonged  physical  or 
emotional  excitement,  and  errors  in  diet  seem  to  excite  it. 

Symptoms. — The  disease  usually  begins  abruptly  with 
chilliness,  headache,  malaise,  and  fever  which  soon  attains  a 
maximum  of  102°  or  103°.  The  face  is  flushed  ;  the  pulse  is 
full  and  rapid  ;  the  urine  is  scanty  and  high  colored ;  the 
tongue  is  coated  ;  the  appetite  is  lost ;  and  the  bowels  are  con- 
stipated. There  is  no  characteristic  eruption,  but  herpes  is 
frequently  observed  on  the  lips. 

The  disease  lasts  from  a  few  days  to  two  weeks,  and  may 
end  by  crisis  or  lysis. 

Diagnosis. — Care  must  be  taken  to  exclude  local  inflam- 
mations, such  as  gastritis,  tonsillitis,  and  pneumonia. 

Typhoid  Fever. — At  first  the  diagnosis  may  be  impossible, 
but  the  absence  of  diarrhoea,  tympanites,  abdominal  tender- 
ness, splenic  enlargement,  and  eruption  will  soon  make  the 
diagnosis  apparent. 

Remittent  Fever, — The  history,  locality,  splenic  enlargement, 
and  hsematozoa  in  the  blood  will  serve  to  distinguish  this  dis- 
ease from  simple  continued  fever. 

Peognosis. — Favorable. 

Teeatment. — Absolute  rest  in  bed.  A  liquid  diet.  Re- 
peated small  doses  of  calomel  may  be  employed  to  relieve  the 
constipation. 

The  fever  may  be  controlled  by  sponging  with  water  and 
alcohol  or  by  the  use  of  some  mild  refrigerant  mixture  like  the 
following : — 

Tinct.  aconit.  rad.,  gtt.  iij  ; 
Spt.  sether.  nitrosi,  f§ss  ; 
Liquor,  aramon.  acetat.,  q.  s.  ad  f^iij. — M. 
Sig. — A  dessertspoonful  every  two  hours  to  a  child  of  four  years. 


TYPHOID  FEVER.  251 

TYPHOID  FEVER. 

(Enteric  Fever,  Typhus  Abdomiualis.) 

Definition. — An  acute  infectious  disease,  excited  by  a 
special  bacillus,  characterized  anatomically  by  definite  lesions 
in  Peyer's  patches,  mesenteric  glands,  and  spleen ;  and  mani- 
fested clinically  by  fever,  headache,  stupor,  abdominal  disten- 
tion and  tenderness,  diarrhoea,  enlargement  of  the  spleen,  and 
a  rose-colored  abdominal  rash. 

Etiology. — Predisposing  causes  :  Autumn  season,  early 
adult  life,  and  a  personal  susceptibility. 

Exciting  cause  :  The  bacillus  of  Eberth.  The  intestinal 
discharges  are  the  source  of  the  contagion,  and  drinking-water 
contaminated  by  them  becomes  the  chief  medium  of  trans- 
mission. 

Pathology. — The  characteristic  lesions  are  found  in  the 
abdominal  lymphatics,  namely,  in  Peyer's  patches,  solitary 
glands,  and  mesenteric  glands.  The  changes  in  Peyer's  glands 
are  best  studied  in  the  lower  part  of  the  ileum,  which  should 
be  opened  on  the  side  of  the  mesenteric  attachment. 

In  the  first  few  days  the  glands  are  swollen  and  hypersemic ; 
later  there  is  a  marked  cell-proliferation,  the  bloodvessels  are 
compressed,  and  the  glands  become  pale  and  prominent  (me- 
dullary infiltration).  If  the  disease  advances,  necrosis  sets  in 
about  the  second  week;  the  glands  become  yellow  and  soft 
and  discharge  their  contents,  leaving  behind  irregular  oval 
ulcers  with  swollen  and  undermined  edges,  and  with  smooth 
bases  formed  by  the  submucous  coat,  muscular  coat,  or  perito- 
neum. In  the  fourth  week  cicatrization  begins,  and  the  gland 
is  ultimately  replaced  by  a  smooth  depressed  scar. 

In  addition  to  these  glandular  lesions,  the  mucous  membrane 
of  both  large  and  small  intestines  shows  catarrhal  changes. 

In  mild  cases  the  stage  of  ulceration  may  not  be  i^eached, 
the  proliferated  cells  being  removed  by  fatty  degeneration  and 
absorption  without  rupture  of  the  gland.  The  solitary  and 
mesenteric  glands  pass  through  similar  changes,  but  the  latter 
rarely  rupture.  Other  lesions  are  found  which  are  not  charac- 
teristic.    The  spleen  is  soft  and  swollen,  and  occasionally  rup- 


252 


ACUTE   INFECTIOUS   DISEASES. 


tares.  The  liver,  kidneys,  heart,  and  muscles  reveal  paren- 
chymatous degeneration.  The  respiratory  tract  is  commonly 
the  seat  of  catarrhal  inflammation.  In  rare  instances  there 
appears  to  be  a  general  infection  without  lesions  of  the  intes- 
tinal glands  (typhoid  septicaemia). 

Peeiod  of  Incubation. — Two  to  three  weeks. 


Fig.  17. 


Temperature  curve  in  typhoid  fever. 

Symptoms.  Prodromal  Symptoms.  —  Gradual  weakness, 
headache,  vague  pains,  nose-bleed,  and  often  slight  diarrhoea. 

The  Attack.  Fever. — The  temperature  rises  gradually,  reach- 
ing a  maximum  (104°-105°)  in  from  one  to  two  weeks ;  it 
remains  at  this  elevation  for  another  period  of  from  one  to 
two  weeks,  when  a  gradual  defervescence  begins  and  occupies 
a  third  period  lasting  from  one  to  two  weeks.  Throughout 
its  course  the  fever  is  characterized  by  marked  daily  remis- 
sions, the  evening  temperature  being  from  one  to  three  degrees 
higher  than  the  morning. 

In  some  cases,  especially  in  the  young,  the  temperature  rises 
quite  abruptly.  Slight  diurnal  remissions  indicate  a  protracted 
case.  As  defervescence  advances,  the  temperature  becomes 
more  irregular;  the  remissions  are  more  decided,  and  not  in- 
frequently the  higher  temperature  is  recorded  in  the  morning. 
An  abrupt  fall  of  several  degrees  should  suggest  intestinal 
hemorrhage  or  perforation. 

Respiratory  Symptoms. — Hurried  respirations,  slight  cough, 
and  bronchial  rales. 

Circulatory  System. — The  pulse  becomes  rapid,  weak,  and 
dicrotic.     The  rapidity  is  often  less  than  such  temperatures 


TYPHOID    FEVEE.  25;i 

g:enerally  produce.  The  heart-sounds  become  feeble.  The 
first  is  especially  weak  and  resembles  the  second. 

The  Face.- — The  expression  is  dull  and  heavy,  the  cheeks 
are  somewhat  flushed,  the  conjunctivae  are  clear,  and  the  pupils 
dilated. 

The  tongue  is  tremulous ;  at  first  it  is  red  at  the  tip  and 
edges,  and  covered  posteriorly  with  a  whitish  fur.  In  severe 
cases  the  tongue  becomes  dry,  brown,  and  fissured,  and  sordes 
collect  on  the  teeth. 

The  Stomach. — Gastric  symptoms  are  not  common,  but  ob- 
stinate vomiting  sometimes  develops  and  becomes  a  serious 
complication. 

Intestinal  Symptoms. — The  belly  is  distended  with  gas.  Ten- 
derness is  frequently  noted  on  palpation ;  it  may  be  general,  or 
confined  to  the  right  iliac  fossa.  Gurgling  may  also  be  detected 
in  the  latter  region,  but  it  has  little  significance.  Diarrhoea  is 
generally  present,  though  it  is  not  a  constant  symptom.  The 
discharges  vary  in  number  from  three  to  six  or  more  a  day ; 
they  are  thin,  offensive,  and  of  a  yellowish  color  (likened  to 
pea-soup) ;  on  standing,  a  turbid  liquid  rises  to  the  top  and  a 
granular  sediment  falls  to  the  bottom. 

The  Eruption. — This  appears  from  the  seventh  to  the  ninth 
day,  and  is  most  abundant  on  the  abdomen,  though  it  is  not 
infrequently  observed  on  the  chest  and  back.  It  is  composed 
of  small,  slightly  elevated,  rose-colored  spots  which  disappear 
on  pressure.  It  comes  out  in  successive  crops  over  several  days. 
It  may  be  absent  particularly  in  the  old  and  very  young. 
Rarely,  in  malignant  cases,  is  the  eruption  petechial. 

Sudamina  are  also  noted,  and  result  from  free  perspiration. 

Splenic  enlargement  is  rarely  absent.    The  organ  may  rupture. 

Nervous  Symptoms. — Headache,  slight  deafness,  stupor, 
mutterhig  delirium,  twitching  of  the  tendons  (subsultus  ten- 
dinum),  picking  at  the  bedclothes  or  imaginary  objects  (car- 
phologia),  and  coma  vigil  (the  eyes  are  open,  but  the  patient 
is  unconscious). 

The  Blood. — An  examination  of  the  blood  reveals  a  reduc- 
tion in  the  number  of  both  red  and  white  cells. 

Widal  Reaction. — Blood-serum  of  typhoid  patients  when 
mixed  with  a  fresh  bouillon-culture  of  the  typhoid  bacillus, 


254  ACUTE   INFECTIOUS   DISEASES. 

after  the  lapse  of  a  few  hours,  clears  the  liquid  and  throws 
down  a  flocculent  precipitate.  Microscopic  examination 
shows  that  this  precipitation  is  due  to  a  loss  of  the  motility 
of  the  bacilli  and  their  agglutination  or  aggregation  in  clumps. 
The  reaction  does  not  appear,  as  a  rule,  before  the  end  of  the 
seventh  or  eighth  day,  and  may  persist  for  several  mouths  or 
years  after  recovery.  It  can  be  obtained  from  dried  blood 
or  from  blood  collected  in  a  glass  tube  of  small  calibre.  As 
a  means  of  diagnosis  it  is  reliable  only  when  the  serum  is 
mixed  with  the  bouillon-culture  in  no  greater  proportion  than 
1  to  40.  Of  2283  typhoid  cases,  95.57  per  cent,  yielded  the 
reaction  ;  of  1365  non- typhoid  cases,  there  was  no  reaction  in 
98.4  per  cent. 

The  urine  is  febrile  and  often  slightly  albuminous.  Reten- 
tion is  common. 

Convalescence  \»  marked  by  ansemia,  foiling  of  the  hair,  des- 
quamation of  the  cuticle,  aud  often  mental  enfeeblement. 

Varieties.  Mild  Typhoid. — There  is  moderate  fever  with 
marked  remissions  ;  the  diarrhoea  is  slight ;  nervous  symp- 
toms are  often  absent;  the  rash  is  usually  present,  and  often 
abundant. 

Abortive  Typhoid. — There  is  an  abrupt  onset  with  severe 
symptoms,  but  convalescence  follows  in  a  few  days. 

Wcdking  Typhoid. — The  symptoms  are  mild,  and  often  dis- 
regarded by  the  patient,  who  refuses  to  go  to  bed;  but  grave 
symptoms  may  develop  suddenly,  and  death  from  perforation 
is  not  uncommon. 

Typhoid  in  Children. — The  rash  is  often  absent ;  the  fever 
rises  abruptly  ;  cerebral  symptoms  are  marked. 

Complications. — ^Any  symptom  aggravated  constitutes  a 
complication ;  thus  high  fever,  excessive  diarrhcEa,  and  tym- 
panites become  complications. 

Hemorrhage. — This  usually  occurs  during  the  third  week, 
and  is  indicated  by  a  sudden  fall  of  temperature,  followed  by 
dark  red  or  tarry  stools. 

Peritonitis. — This  may  result  from  perforation,  or  from  ex- 
tension by  contiguity.  The  former  is  the  more  common,  and 
is  recognized  by  a  sudden  pain,  a  fall  of  temperture,  disten- 
tion of  the  belly,  and  symptoms  of  peritonitis. 


TYPHOID    FEVER.  255 

Pneumonia  and  hypostatic  congestion  of  the  lungs  are  com- 
mon complications. 

Among  less  frequent  complications  or  sequela?  may  be  men- 
tioned :  Nephritis,  neuritis,  suppurative  cholecystitis,  appen- 
dicitis, pyelitis,  tuberculosis,  temporary  insanity,  parotitis, 
and  phlegmasia  dolens. 

Kelapse  and  Eecrudescence. — Relapses  are  quite  com- 
mon ;  they  repeat  the  symptoms  of  the  original  attack,  but 
they  are  generally  milder  and  of  shorter  duration,  and  seldom 
prove  fatal. 

Recrudescence. — This  is  a  sudden  temporary  elevation  of 
temperature  occurring  during  convalescence,  and  is  not  asso- 
ciated with  a  return  of  the  other  symptoms.  It  is  usually  due 
to  constipation,  excitement,  or  irritating  food. 

Diagnosis. — Acute  miliary  tuberculosis  often  closely  resem- 
bles typhoid  fever.  In  tuberculosis  the  temperature  is  gen- 
erally more  irregular ;  the  abdominal  symptoms  are  less 
marked ;  pulmonary  symptoms,  especially  dyspnoea,  are  more 
marked  ;  the  rash  is  absent ;  tubercles  may  be  detected  on  the 
retina ;  and  symptoms  of  basilar  meningitis  may  be  present, 
such  as  irregular  pupils,  ptosis,  and  strabismus. 

Ulcerative  Endocarditis. — The  diagnosis  may  be  impossible, 
but  the  following  features  would  suggest  endocarditis :  The 
[history  of  a  primary  disease  which  might  induce  ulcerative 
endocarditis ;  irregular  fever  ;  intercurrent  rigors ;  marked 
leucocytosis ;  precordial  pain  and  endocardial  murmurs ; 
and  the  absence  of  a  rose-colored  rash,  of  the  Widal  reac- 
tion, and  of  marked  abdominal  symptoms. 

Enteritis. — The  absence  of  high  fever,  of  eruption,  of  splenic^ 
enlargement,  of  epistaxis,  of  bronchial  catarrh  will  serve  to 
distinguish  enteritis  from  typhoid  fever. 

Ifeningitis. — The  abrupt  onset,  the  early  development  of 
cerebral  symptoms,  the  irregular  fever,  and  the  absence  of  a 
rash  and  of  abdominal  symptoms  will  indicate  meningitis. 

Prognosis. — The  prognosis  should  always  be  guarded.  No 
case  is  too  mild  to  prove  fatal,  and  no  case  is  too  severe  to 
recover.  The  mortality  varies  in  different  epidemics.  In 
private  practice  the  average  is  probably  between  five  and  ten 
.per  cent,,  and  in  hospital  practice  it  is  somewhat  more. 


2^6  ACUTE    INFECTIOUS    DISEASES. 

Continued  high  fever  with  slight  diurnal  remissions,  exces- 
sive diarrhoea,  severe  cerebral  symptoms,  and  repeated  hemor- 
rhages are  unfavorable  features. 

TuEATMENT. — Absolute  rest  in  bed  and  the  enforced  use 
of  the  bed-pan.  The  stools  should  be  rendered  innocuous. 
This  may  be  done  by  dissolving  a  pound  of  chloride  of  lime 
in  four  gallons  of  water,  and  adding  a  quart  of  the  solution 
to  each  discharge,  and  allowing  it  to  remain  in  the  vessel  at 
least  an  hour  before  disposing  of  it.  Soiled  bedclothes 
should  be  thoroughly  boiled. 

The  diet  must  be  liquid,  and  preferably  milk.  From  two 
to  four  pints  should  be  given  in  the  twenty-four  hours,  and 
should  be  so  divided  that  the  patient  shall  receive  a  small 
amount  every  two  hours,  day  and  night.  When  it  causes 
eructations  or  flatulence,  or  is  discharged  undigested,  it  must 
be  mixed  with  lime-water,  or  be  predigested.  Koumiss  is 
often  acceptable.  Meat-broths  may  be  given  to  vary  the 
monotony  of  a  milk  diet.  Cool  water  or  ice  will  be  required 
to  allay  thirst,  and  even  if  the  latter  is  absent,  it  is  well  to 
give  one  or  the  other  at  regular  intervals.  When  the  first 
sound  of  the  heart  weakens  and  the  pulse  becomes  soft,  stimu- 
lants should  be  administered.  It  is  desirable  to  give  the 
alcohol  with  the  milk  so  as  to  stimulate  the  stomach  to  digest 
the  latter,  and  at  the  same  time  to  diminish  the  number  of 
administrations  of  food  and  medicine.  From  four  to  eight 
ounces  of  brandy  or  whiskey  may  be  required  in  the  twenty- 
four  hours,  the  amount  being  determined  by  the  general  effect. 
When  additional  stimulation  is  required  strychnine  is  a  valu- 
able adjunct. 

When  the  tongue  becomes  dry  and  brown,  the  belly  much 
distended,  and  low  nervous  symptoms  develop,  turpentine 
will  be  found  an  invaluable  stimulant.  Five  to  ten  minims 
may  be  given  in  capsule  or  emulsion  every  two  or  four  hours. 

Antiseptic  remedies  have  been  strongly  advocated,  but  their 
efficiency  has  not  been  clearly  demonstrated.  Thymol,  naphthol, 
carbolic  acid,  chlorine-water,  iodine,  and  calomel  are  the  anti- 
septics which  have  been  recommended. 

The  use  of  the  cold  bath  or  the  cold  pack  will  be  found  an 
excellent  method  of  controlling  fever  and  of  preventing  the 


TYPHOID   FEVER.  257 

development  of  severe  nervous  symptoms.  It  is  especially  val- 
uable as  a  stimulant  to  the  nerve-centres,  and  may  be  employed 
whenever  the  temperature  exceeds  ]02f°.  Hemorrhage  and 
perforation  contraindicate  its  use.     (See  page  247.) 

Fever. — When  circumstances  prevent  the  use  of  the  cold 
bath,  sponging  with  cool  water  and  the  administration  of  such 
antipyretics  as  quinine  (gr.  xx-xxx)  or  antipyrin  (gr.  v-x) 
may  be  substituted. 

Diarrhoea. — When  diarrhoea  exceeds  more  than  three  or 
four  stools  a  day,  it  is  well  to  check  it  by  an  ojDium  sup- 
pository, or  by  bismuth  or  nitrate  of  silver  by  the  mouth. 

^   Pulv.  opii,  gr.  iij  ; 

01.  theobrom.,  q.  s. — M. 
Ft.  in  siippos.  No.  vi. 
Sig. — One,  two  or  three  times  daily. 

Or— 

^   Morpb.  sulph.,  gr.  j  ; 

Creosot.,  gtt.  vj  ; 

Bismuth,  subnit. ,  giij. — M. 
Ft.  in  chart.  'No.  xii. 
Sig. — One  every  two  or  three  hours. 

Or— 

J^l:.  Argenti  nit.,  gr.  v  ; 
Ext.  opii,  gr.  iv.— M. 
Ft.  in  pil.  No.  XX, 
Sig. — One  every  three  hours. 

Constipation. — This  may  be  relieved  by  an  enema  of  soap 
and  water,  or  by  broken  doses  of  calomel. 

Tympanites. — Turpentine  stupes.  Turpentine  or  thymol  in- 
ternally.    In  grave  cases,  rectal  intubation. 

Hemorrhage. — An  ice-bag  to  the  right  iliac  fossa.  Morphine 
(gr.  I)  with  ergotine  (gr.  v-x)  hypodermically.  Turpentine 
or  gallic  acid  may  be  administered  by  the  mouth. 

Perforative  Peritonitis. — About  1  or  2  per  cent,  of  typhoid 
cases  end  in  perforation.  This  complication  is  almost  inva- 
riably fatal.  Morphine  should  be  given  freely.  Operative 
interference  offers  some  hope  in  selected  cases.  In  30  opera- 
tions there  were  6  recoveries. 

Heart-failure. — When  alcohol  is  being  used  in  large 
amounts  and  the  symptoms  of  heart-weakness  still  persist, 
17 


258  ACUTE    INFECTIOUS    DISEASES. 

such  remedies  as  aromatic  spirits  of  ammonia,  ether,  strych- 
nine, digitalis,  or  cocaine  may  prove  useful. 

Grave  Nervous  Synvptoms. — Delirium,  subsultus,  insomnia, 
etc.,  are  best  controlled  by  cold  bathing.  Nerve  sedatives, 
like  the  bromide  of  potassium,  musk,  hyoscine,  sulphonal, 
and  camphor,  are  sometimes  required. 

TYPHUS  FEVER. 

(Ship  Fever,  Jail  Fever.) 

Definition. — An  acute  contagious  disease  unassociated 
with  any  characteristic  lesions  of  the  solids,  and  manifested  by 
great  prostration,  a  petechial  rash,  marked  nervous  symptoms, 
and  high  fever  which  defervesces  by  crisis  in  from  ten  to 
fourteen  days. 

Etiology. — It  is  excited  by  an  unknown  poison  which  is 
capable  of  being  carried  in  clothes  (fomites).  It  is  rare  in 
America,  but  not  uncommon  in  England  and  Ireland.  Bad 
food,  impure  water,  overcrowding,  and  foul  air  are  predis- 
posing factors. 

Pathology. — There  are  no  characteristic  lesions  of  the 
solids.  As  in  other  fevers,  the  liver  and  spleen  are  swollen, 
and  the  tissues  reveal  fatty  and  parenchymatous  degeneration. 
The  blood  shows  a  peculiar  change  :  it  is  dark,  fluid,  and 
stains  the  lining  of  the  heart  and  great  bloodvessels  bright  red. 

Period  of  Incubation. — A  few  hours  to  two  weeks. 

Symptoms. — Typhus  fever  begins  abruptly  with  pain  in 
the  head,  back,  and  limbs ;  extreme  prostration ;  and  fever 
which  reaches  its  maximum  (104°-105°)  in  two  or  three  days. 
The  temperature  remains  high  for  about  ten  days,  when  it 
falls  by  crisis. 

The  pulse  is  rapid,  weak,  and  often  dicrotic.  The  tongue 
is  tremulous,  and  usually  covered  with  a  whitish  fur ;  but  in 
bad  cases  it  becomes  black  and  rolled  up  like  a  ball  in  the  back 
of  the  mouth. 

The  face  is  dusky ;  the  conjunctivae  are  injected ;  and  the 
pupils  are  contracted. 

Nervous  Symptoms. — These  are  prominent,  and  consist  of 


TYPHUS    FEVER.  •      259 

headache,  stupor,  delirium,  subsultus  tendinum,  carphologia, 
and  coma  vigil. 

The  Eruption. — About  the  fourth  or  fifth  day  rose-colored 
spots  appear  over  the  body  ;  these  rapidly  become  hemorrhagic, 
or  petechial,  and  fail  to  disappear  on  pressure.     There  is  a 

Fig.  18. 


Temperature  chart  of  typhus.  . 

distinct  relation  between  the  amount  of  eruption  and  the 
severity  of  the  attack.  In  addition  to  this  "  mulberry  rash," 
there  is  often  a  diffuse,  dark-red  subcuticular  mottling. 

G astro-intestinal  Symptoms. — The  stomach  is  retentive,  and 
the  bowels  are  constipated. 

Urine. — The  urine  is  scanty,  high-colored,  and  often  albu- 
minous. 

Complications. — Hyperpyrexia,  catarrhal  pneumonia, 
hypostatic  congestion  of  the  lungs,  nephritis,  and  parotid 
abscess. 

Diagnosis,  Cerebrospinal  Meningitis.  —  In  this  affection 
the  pain  in  the  back  is  greater.  The  fever  is  very  irregular ; 
there  is  greater  tendency  to  opisthotonos  and  facial  palsies  ;  and 
the  eruption,  though  it  may  resemble  that  of  typhus,  is  incon- 
stant and  without  a  special  time  for  appearing. 

Typhoid  Fever. — The  resemblance  is  in  the  nervous  phe- 
nomena only.  In  typhoid  the  fever  rises  and  falls  very 
gradually ;  the  eruption  appears  later,  remains  rose-red,  and 
does  not  become  petechial ;  the  face  is  not  dusky,  the  eyes  are 
not  injected  ;  and  there  are  marked  abdominal  symptoms. 

Prognosis. — The  mortality  is  much  greater  than  in  typhoid 


260  ACUTE   INFECTIOUS    DISEASES. 

fever.  Advanced  years  and  alcoholism  render  the  prognosis 
decidedly  unfavorable. 

Treatment. — Isolation  ;  absolute  rest ;  liquid  diet.  There 
is  no  specific  treatment.  Alcohol  is  nearly  always  required. 
Quinine  and  mineral  acids  are  useful  tonics. 

Pyrexia,  nervous  phenomena,  and  heart-failure  should  be 
treated  as  in  typhoid  fever. 


RELAPSING  FEVER. 

(Spirillum  Fever,  Famine  Fever.) 

Definition. — An  acute  contagious  disease  excited  by  the 
sjDirochaete  of  Obermaier,  and  characterized  by  paroxysms  of 
high  fever  which  last  five  or  six  days  and  are  followed  by  in- 
termissions of  a  similar  duration. 

Etiology. — The  exciting  cause  is  the  spirocheete  of  Ober- 
maier, a  spiral-shaped  microbe  three  or  four  times  as  long 
as  the  diameter  of  a  red  blood-corpuscle.  Bad  water,  poor 
food,  overcrowding,  and  foul  air  predispose  to  epidemics. 
The  disease  is  highly  contagious. 

Pathology.  —  There  are  no  characteristic  lesions.  The 
liver  and  spleen  are  much  enlarged,  and  the  latter  is  frequently 
the  seat  of  infarctions.  There  is  usually  catarrhal  inflamma- 
tion of  the  stomach  and  bile-ducts.  The  spirochsete  is  found  in 
the  blood  during  life,  but  only  during  the  paroxysms ;  after 
death  it  is  found  in  all  the  organs. 

Period  of  Incubation. — Five  to  eight  days. 

Symptoims. — The  disease  begins  abruptly  with  a  chill  fol- 
lowed by  fever,  Avhich  reaches  its  maximum  (105°— 106°)  in 
twenty-four  hours,  and  remains  high  for  from  five  to  seven 
days,  when  it  falls  by  crisis.  After  an  intermission  of  five  or 
six  days  it  again  rises  rapidly  and  remains  high  for  a  similar 
period.  Convalescence  usually  begins  at  the  end  of  the  second 
paroxysm,  but  it  may  not  begin  until  after  the  third  or  fourth. 
Other  noteworthy  symptoms  are  intense  pains  in  the  head, 
back,  and  limbs ;  the  spirochsete  in  the  blood  ;  and  frequently 
jaundice. 


CEEEBBO-SPINAL    FEVER.  261 

Complications. — Hyperpyrexia,  nephritis,  pneumonia,  and 
ophtlialmia. 

Diagnosis.  Rheumatie  Fever. — The  history,  irregular  fever, 
acid  sweats,  and  the  absence  of  spirilli  and  of  jaundice  will 
serve  to  distinguish  rheumatism  from  relapsing  fever. 

Remittent  Fever. — In  this  disease  the  fever  remits,  but  does 

Fig.  19. 


Temperature  curve  in  relapsing  fever. 

not  intermit;  the  paroxysms  are  more  frequent;  and  instead 
of  spirilli,  hsematozoa  are  found  in  the  blood. 

Yellow  Fever. — The  single  remission  on  the  second  or  third 
day,  the  bloody  vomit,  and  the  absence  of  spirilli  and  of  splenic 
enlargement  will  indicate  yellow  fever. 

Prognosis. — Favorable  in  uncomplicated  cases. 

Treatment. — Isolation  ;  rest ;  liquid  diet.  As  a  general 
tonic,  quinine  is  useful.  For  the  pains,  antipyrin,  phenacetin, 
or  morphine  may  be  given  internally,  and  rubefacients  used 
locally.  For  the  irritable  stomach  hot  fomentations  may  be 
applied  to  the  epigastrium,  and  small  doses  of  calomel  and 
soda  administered  internally. 

CEREBROSPINAL  FEVER. 

(Epidemic  Cerebro-Spinal  Meningitis,  Spotted  Fever.) 

Definition. — A  specific  infectious  disease  characterized 
anatomically  by  inflammation  of  the  cerebro-spinal  meninges, 
and  clinically  by  intense  pain  in  the  head,  back,  and  limbs. 


k 


262  ACUTE   INFECTIOUS   DISEASES. 

convulsions,  irregular  fever,  and  frequently  by  a  petechial 
eruption. 

Etiology. — The  disease  may  be  sporadic  or  epidemic. 
Overcrowding,  poor  food,  foul  air,  and  bad  drinking-water 
seem  to  predispose  to  epidemics.  Outbreaks  are  most  common 
in  the  winter  and  spring.  The  young  are  more  susceptible 
than  the  old.  The  disease  is  not  contagious  ;  the  method  of 
transmission  is  still  unknown. 

The  Exciting  Cause. — This  is  the  diplococcus  intracellu- 
laris  of  Weichselbaum.  In  the  tissues  this  organism  is  found 
chiefly  in  the  leucocytes  of  the  exudation. 

Pathology. — In  most  cases  the  membranes  of  the  brain 
and  cord  are  deeply  congested  aud  opaque.  Lymph  and  pus 
are  found  both  at  the  base  and  on  the  convexity  of  the  brain, 
especially  in  the  fissures  and  along  the  bloodvessels.  The 
spinal  meninges  present  similar  changes,  the  posterior  surface 
of  the  cord  being  particularly  involved. 

The  liver  and  spleen  are  engorged  and  the  muscles  reveal 
granular  degeneration.  In  rapidly  fatal  cases  the  lesions  are 
very  slight. 

Symptoms.  Common  Form. — The  disease  generally  begins 
abruptly  with  a  chill,  followed  by  vomiting  and  excruciating 
pain  in  the  head,  back,  and  limbs.  The  muscles  of  the  neck 
and  back  become  rigid  and  contracted,  so  that  the  head  is  bent 
backward  and  the  back  is  straightened;  in  severe  cases  the 
body  may  be  arched  in  a  state  of  opisthotonos.  The  mind  is 
soon  affected  ;  delirium  is  rarely  absent,  and  in  severe  cases  it 
is  followed  by  stupor  and  coma. 

Involvement  of  the  Cranial  Nerves. — Pressure  of  the  exudate 
upon  the  cranial  nerves  may  produce  tlie  following  symptoms  : 
Nystagmus  (tremor  of  the  eyeball);  strabismus;  ptosis;  irregu- 
lar, sluggish  pupils ;   and  partial  deafness  or  blindness. 

Involvement  of  the  Spinal  Nerves. — There  is  extreme  cutaneous 
hypersesthesia,  so  that  the  slightest  touch  excites  pain.  The 
muscles  of  the  extremities  are  stiff  and  may  twitch,  but  are 
rarely  palsied.  The  patellar  reflex  is  usually  diminished. 
The  joints  are  occasionally  red,  swollen,  and  painful. 

Febrile  Symptoms. — The  temperature  is  irregular  in  its 
course  and  indefinite  in  its  duration  ;  ordinarily  it  ranges  be- 


CEREBRO-SPINAL    FEVER.  2G3 

tween  101°  and  103°,  but  in  some  cases  it  is  almost  normal, 
and  in  others  it  is  very  high.  The  pulse  is  rapid  and  full ; 
the  bowels  are  constipated  ;  and  the  urine  may  contain  albumin 
and  sugar.     Polyuria  is  an  occasional  symptom. 

The  Eruption. — The  eruption  is  neither'  constant  nor  pecu- 
liar. In  many  cases  a  blotchy  purpuric  rash  appears  over  the 
entire  body.  Herpes  facialis  is  also  frequently  observed.  In 
other  cases  urticaria,  or  a  roseolar  or  erythematous  rash  ap- 
pears. 

Tlie  Blood. — licucocytosis  is  always  present. 

Lumbar  Puncture. — In  a  large  proportion  of  the  cases 
diplococci  are  found  either  on  microscopic  examination  or 
in  culture. 

The  duration  is  from  a  few  hours  to  several  weeks.  In 
favorable  cases,  convalescence  is  very  protracted. 

Fulminant  Form. — There  is  an  abrupt  onset  with  a  chill, 
followed  by  vomiting,  headache,  moderate  fever,  convulsions, 
a  petechial  or  purpuric  rash,  and  death  in  a  few  hours  from 
collapse. 

Abortive  Form. — The  disease  begins  abruptly  with  grave 
symptoms,  but  terminates  in  a  few  days  in  recovery 

Intermittent  Form. — The  fever  is  characterized  by  inter- 
missions or  marked  remissions  which  occur  daily  or  every 
other  day. 

Diagnosis.  Typhoid  Fever. — The  gradual  onset,  the  regu- 
lar fever,  the  diarrhoea  and  tympanites,  the  Widal  reaction, 
and  the  absence  of  rigidity,  of  intense  pain  in  the  back  and 
limbs,  of  facial  palsies  and  of  herpes,  will  separate  typhoid 
from  cerebro-spinal  fever. 

Typhus  Fever. — The  regular  fever,  the  absence  of  intense 
pain  in  the  back  and  limbs,  of  facial  palsies,  and  of  muscular 
rigidity,  will  distinguish  typhus  from  cerebro-spinal  fever. 

Acute  articular  rheumatism  may  resemble  cerebro-spinal 
meningitis,  but  the  early  involvement  of  the  joints,  the  acid 
sweats,  and  the  absence  of  rigidity,  of  eruption,  and  of  facial 
palsies,  will  distinguish  it  frorn  cerebro-spinal  meningitis. 

Tuberculous  Meningitis. — In  this  disease  the  onset  is  less 
abrupt ;  there  is  less  tendency  to  opisthotonos ;  herpes  is  rare ; 


264  ACUTE    INFECTIOUS    DISEASES. 

and  petechise  are  always  absent.  Tuberculous  meningitis  in 
the  adult  is  always  secondary  to  tuberculosis  elsewhere. 

Prognosis. — The  mortality  varies  in  different  epidemics 
from  20  to  80  per  cent.  The  prognosis  should  always  be 
guarded ;  the  mildest  cases  may  prove  fatal.  Severe  cerebral 
symptoms  usually  indicate  a  fatal  termination. 

Complications  and  Sequels. — Defective  vision  from 
inflammation  of  the  cornea  or  retina,  or  from  atrophy  of  the 
optic  nerve ;  defective  hearing  from  inflammation  of  the 
auditory  nerve,  or  from  suppurative  inflammation  of  the 
internal  or  middle  ear;  pneumonia  ;  arthritis ;  aphasia ;  periph- 
eral palsies ;  imbecility  ;  chronic  hydrocephalus ;  and  per- 
sistent headache  from  chronic  meningitis. 

Treatment. — A  liquid  or  semi-liquid  diet.  Ice-bags  may 
be  applied  to  the  head  and  along  the  spinal  column.  Pain 
and  restlessness  should  be  relived  by  morphine,  bromides,  or 
chloral.  Morphine  is  especially  efficacious,  and  may  be  injected 
along  the  course  of  the  most  painful  nerve-trunks.  Dry  or 
wet  cups  over  the  spine  are  sometimes  useful.  Iodide  of 
potassium  (gr.  v-x  thrice  daily)  may  be  administered  internally. 
Dr.  Pepper  recommends  quinine  (gr.  v  thrice  daily)  with  the 
fluid  extract  of  ergot  (5j  every  three  or  four  hours).  When 
the  pulse  weakens,  stimulants  should  be  given  freely.  High 
fever  may  be  controlled  by  sponging  with  cold  water,  by  the 
cold  pack,  or  by  the  internal  use  of  phenacetin  or  antipyrin. 

During  convalescence,  iodide  of  potassium  as  an  absorbent, 
tonics,  and  blisters  to  the  spine  are  indicated. 

MAIiARIAL  FEVER. 

(Chills  and  Fever,  Fever  and  Ague,   Swamp  Fever.) 

Definition. — A  specific  non-contagious  disease,  invariably 
associated  with,  and  probably  excited  by,  the  hcemocytozoa  of 
Laveran,  and  characterized  by  splenic  enlargement,  by  fever 
with  periodic  intermissions  or  remissions,  and  by  a  tendency 
to  extreme  anaemia. 

Etiology. — A  warm  climate  and  the  summer  season,  a 
moist   atmosphere ;    low,  badly-drained   soil ;   and   decaying 


MALARIAL    FEVER.  265 

vegetable  matter  are  the  conditions  which  favor  the  develop- 
raentof  the  malarial  poison. 

Special  Predisposmg  Causes. — Residents  in  the  lowlands  are 
more  liable  to  be  infected  than  those  w^ho  dwell  on  the  hills ; 
one  attack  seems  to  predispose  to  others ;  visitors  to  malarial 
districts  are  more  susceptible  than  permanent  residents;  in 
the  night  and  in  the  early  morning  the  air  is  thoroughly  im- 
pregnated with  the  miasm,  and  exposure  at  such  times  is  very 
apt  to  be  followed  by  infection. 

Exciting  Cause. — Certain  organisms  belonging  to  the  pro- 
tozoa, and  known  as  the  hcemocytozoa,  are  probably  the  exciting 
agents.  Recent  investigations  indicate  that  the  mosquito,  by 
means  of  its  bite,  is  an  important  conveyer  of  the  infection. 

Manifestations. — Malarial  intoxication  may  manifest  it- 
self, as  (1)  intermittent  fever  ;  (2)  remittent  fever;  (3)  perni- 
cious malarial  fever  ;  and  (4j  chronic  malarial  cachexia. 

Pathology. — Various  forms  of  hsemocytozoa  are  noted, 
some  of  which  are  distinct  species,  while  others  represent  simply 
phases  of  existence  in  the  life-history  of  the  same  oi'ganism. 
A  small  colorless  amoeboid  body  enters  the  red  blood-corpuscle, 
increases  in  size,  and  becomes  pigmented  from  the  heemoglobiu 
of  the  corpuscle.  When  the  host  is  destroyed  the  granules  of 
pigment  collect  in  the  centre  of  the  organism,  which  finally 
divides  into  a  number  of  small  hyaline  bodies,  each  of  which 
begins  a  new  cycle  of  existence.  The  chills  or  paroxysms 
occur  at  the  time  of  sporulatiou,  and  are  doubtless  due  to  the 
production  of  a  toxine.  The  parasite  of  tertian  intermittent 
fever  requires  forty-eight  hours  to  complete  its  cycle  of  exist- 
ence ;  hence,  when  a  single  group  of  these  parasites  exists  in 
the  blood  paroxysms  occur  every  other  day.  If,  however, 
two  groups  coexist  and  sporulate  on  alternate  days,  a  paroxysm 
occurs  daily  (quotidian  intermittent  fever).  The  parasites  of 
quartan  intermittent  fever  require  seventy-two  hours  in  which 
to  develop  and  undergo  sporulatiou  ;  hence  a  single  group  of 
these  organisms  in  the  blood  excites  a  chill  every  fourth  day. 
When  two  groups  coexist  a  chill  occurs  on  two  successive 
days,  and  is  followed  by  a  daily  intermission.  When  three 
groups  coexist  a  chill  occurs  every  day  (quotidian  intermittent 
fever).  The  life-history  within  the  body  of  the  parasite  of 
remittent  fever  is  not  definitely  known.     Its  cycle  of  existence 


266  ACUTE    INFECTIOUS    DISEASES. 

occupies  from  twenty-four  to  forty-eight  hours.  Organisms 
with  flagella  sometimes  develop  from  fully-grown  hsemocy- 
tozoa,  but  their  significance  is  unknown. 

Fig.  20. 


Various  forms  of  haemocytozoa. 


In  advanced  malaria  the  blood  shows  a  diminished  number 
of  red  blood-corpuscles  and  an  abundance  of  free  pigment 
(melansemia).  The  spleen  is  greatly  swollen  and  deeply  pig- 
mented (ague-cake) ;  the  liver  is  moderately  enlarged  and 
pigmented.  All  the  organs,  including  the  brain  and  spinal 
cord,  are  discolored  by  the  liberated  pigment. 

Intermittent  Fever. 

Symptoms. — The  characteristic  features  of  this  form  of 
malarial  infection  are :  The  intermittent  type  of  fever,  the 
enlargement  of  the  spleen,  the  hsemocytozoa  in  the  blood,  and 
the  occurrence  of  regular  intervals  of  paroxysms  divided  into 
three  stages — cold,  hot,  and  sweating. 

Cold  Stage. — Malaise;  headache;  great  chilliness.  The 
features  are  pinched ;  the  lips  are  blue ;  the  surface  of  the 
body  is  cold  and  covered  with  eutis  anserina  (goose-flesh), 
although  the  rectal  temperature  is  high  (104°-105°).  Vomit- 
ing may  occur.  The  chill  lasts  from  a  few  minutes  to  an 
hour  or  two. 

Hot  Stage. — The  surface  temperature  gradually  rises ;  the 
skin  becomes  hot;  the  face  flushed  ;  the  eyes  injected  ;  and  the 
pulse  full  and  rapid.  The  temperature  in  the  axilla  may  reach 
106°  or  107°.  The  patient  complains  of  severe  pain  in  the  head, 
back,  and  limbs,  and  of  intense  thirst.  The  urine  is  scanty  and 
dark-colored.    This  stage  usually  lasts  from  one  to  five  hours. 

Sweating  Stage. — The  fever  gradually  subsides;  the  pain 


MALARIAL   FEVER.  267 

grows  less ;  free  perspiration  follows ;  and  the  patient  falls  to 
sleep,  from  which  he  awakes  feeling  fairly  well. 

Varieties. —  When  tlie  paroxysms  occur  every  day,  the 
disease  is  termed  quotidian  intermittent;  every  other  day, 
tertian  intermittent;  every  fourth  day,  quartan  intermittent. 

Prognosis. — Always  favorable.  Even  when  no  treatment 
is  instituted  the  paroxysms  gradually  subside.  Chronic  ma- 
larial cachexia  dometimes  results  from  the  acute  disease. 

Remittent  Fever. 

(j^stivo-autumnal  Fever,  Bilious  Remittent  Fever,  Jung-le  Fever.) 

In  temperate  zones  remittent  fever  is  observed  chiefly  in  the 
autumn.  The  h?emocytozoa  appear  at  first  as  small  round 
motile  bodies  with  very  little  pigment  in  them,  but  soon  these 
are  replaced  by  ovoid  or  crescentic  bodies  containing  central 
masses  of  coarse  pigment. 

Symptoms. — Malaise  with  moderate  chilliness,  followed  by 
a  continuous  fever  which  daily  remits.  The  maximum  tem- 
perature ranges  from  103°  to  106°,  and  while  this  lasts  the 
skin  is  hot,  the  face  is  flushed,  the  eyes  are  injected,  the  pulse 
is  full  and  rapid,  the  urine  is  scanty,  and  the  patient  complains 
of  pain  in  the  head  and  limbs.  Definite  paroxysms  may  or 
may  not  be  present.  Delirium  is  sometimes  noted  ;  vomiting 
often  occurs ;  and  jaundice  may  develop  from  destruction  of 
the  red  blood-corpuscles  and  liberation  of  their  pigment.  The 
spleen  is  enlarged,  and  an  examination  of  the  blood  reveals 
lipemocytozoa. 

In  some  cases  the  symptoms  resemble  typhoid  fever,  and  to 
these  the  term  typho-malarial  fever  has  been  applied. 

Diagnosis.  Typhoid  Fever. — The  absence  of  diarrhoea,  of 
tympanites,  of  eruption^  and  of  a  gradual  rise  in  temperature, 
and  the  presence  of  hsemocytozoa  and  of  marked  remissions 
will  serve  to  separate  remittent  fever  from  typhoid. 

Yellow  Fever. — The  splenic  enlargement,  the  haemocytozoa, 
the  multiple  remissions,  and  the  absence  of  bloody  vomit  will 
separate  remittent  from  yellow  fever. 

Prognosis. — Favorable ;  the  average  duration  is  from  one 
to  two  weeks. 


268  ACUTE   INFECTIOUS   DISEASES. 

Pernicious  Malarial  Fever. 

(Congestive  Chills,  Malignant  Malaria.) 

Pernicious  malarial  fever  is  found  chiefly  in  the  tropics. 
It  is  invariably  associated  with  the  parasite  of  remittent 
fever.  There  are  three  varieties :  algid,  comatose,  and  hem- 
orrhagic. 

Symptoms.  Algid. — The  symptoms  resemble  the  cold 
stage  of  cholera.  The  surface  is  cold ;  the  temperature  may 
be  subnormal ;  there  is  great  prostration ;  the  features  are 
pinched ;  the  pulse  is  feeble.  Vomiting  and  purging  may 
follow ;  death  often  results  in  collapse. 

Comatose. — There  is  delirium,  rapidly  followed  by  stupor 
and  coma ;  the  latter  may  or  may  not  be  associated  with  con- 
vulsions. The  skin  is  hot ;  the  face  is  flushed ;  the  eyes  in- 
jected ;  and  the  temperature  high.  The  symptoms  gradually 
disappear,  but  unless  the  patient  is  speedily  cinchonized  they 
return  and  commonly  prove  fatal. 

Hemorrhagic. — In  this  form  hemorrhages  occur  from  the 
mucous  membranes,  especially  from  the  kidneys,  stomach,  and 
bowels,  and  the  patient  is  frequently  jaundiced. 

Diagnosis. — The  algid  form  may  resemble  cholera,  but  the 
history,  the  absence  of  an  epidemic,  and  the  presence  of  the 
heematozoa  in  the  blood  will  render  the  diagnosis  apparent. 

Yellow  Fever. — The  hemorrhagic  form  may  resemble  yellow 
fever,  but  the  splenic  enlargement,  the  late  appearance  of  jaun- 
dice, the  presence  of  hsemocytozoa  in  the  blood,  and  the  absence 
of  an  epidemic  will  serve  to  distinguish  the  two  diseases. 

Prognosis. — Extremely  guarded ;  the  first  paroxysm  rarely 
kills,  but  unless  the  patient  is  thoroughly  cinchonized  a  second 
one  may  prove  fatal. 

Chronic  Malarial  Cachexia. 

Definition. — A  chronic  manifestation  of  malaria,  charac- 
terized by  ansemia,  by  a  sallow  appearance  of  the  skin,  and  by 
splenic  enlargement. 

Etiology.- — It  may  result  from  repeated  attacks  of  the 


MALARIAL    FEVER.  269 

acute  disease,  or  it  may  develop  as  a  primary  condition  from 
slow  infection. 

Symptoms. — Tlie  patient  is  thin  and  pale ;  the  complexion 
is  of  a  dirty  yellow  or  muddy  hue ;  fever  is  often  absent ;  if 
present,  it  is  slight  and  irregular;  the  spleen  is  considerably 
enlarged.  There  is  great  weakness  from  the  attending  anaemia. 
Headache  and  neuralgia  are  common  symptoms.  Hsematuria 
is  sometimes  observed. 

Diagnosis.  Leuccemia. — The  history,  the  absence  of  leuco- 
cytosis  and  of  lymphatic  enlargements,  and  the  presence  of 
hsemocytozoa  in  the  blood  will  indicate  malaria. 

Prognosis. — Guarded.  When  tlie  spleen  is  very  large  and 
there  is  extreme  anaemia,  recovery  rarely  follows. 

Other  Manifestations  of  Malaria. 

One  of  the  following  conditions  may  be  the  chief  manifes- 
tation of  malarial  intoxication  :  !N^euralgia,  headache,  hsema- 
turia, purpura,  orchitis,  or  paraplegia. 

Malarial  infection  seems  to  predispose  to  certain  cases  of 
dysentery,  of  pneumonia,  and  of  amyloid  degeneration  of  the 
viscera. 

Treatment  of  Malarial  Diseases.  Prophylaxis. — 
Patients  living  in  malarial  districts  should  avoid  the  night 
and  early  morning  air,  and  should  take  quinine  (gr.  iij-v  a 
.day)  during  the  season  in  which  the  disease  is  prevalent. 

Cold  Stage  of  Intermittent. — Cover  the  patient  with  blankets, 
and  apply  hot  cans  or  hot  bottles  to  the  feet.  When  the  chill  is 
severe  and  prolonged,  morphine  is  very  useful;  it  may  be  given 
hypodermically.  Hoifmann's  anodyne  may  be  employed 
as  a  substitute.  Inhalations  of  nitrite  of  amyl  are  followed 
by  dilatation  of  the  superficial  bloodvessels,  and  in  this  way 
serve  to  shorten  the  chill. 

Hot  Stage  of  Intermittent — Sponge  the  body  with  cool 
water,  and  if  the  symptoms  are  severe  phenacetin  may  be 
given  to  lower  the  temperature  and  to  lessen  the  pain. 

The  Interval. — It  is  well  to  begin  the  treatment  by  the 
administration  of  a  laxative,  and  calomel  may  be  selected. 
This  should  be  followed  by  quinine  (gr.  xv-xx)  in  divided 
doses,  so  that  the  last  dose  is  taken  two  hours  before  the  time 


270  ACUTE    INFECTIOUS    DISEASES. 

of  the  expected  paroxysm.  In  children,  quinine  may  be  given 
in  lozenges  made  with  chocolate  and  sugar.  In  adults,  it  is 
best  administered  in  fresh  pills  or  in  capsules.  These  doses 
of  quinine  should  be  continued  until  the  paroxysms  disappear, 
when  the  amount  may  be  gradually  diminished.  The  treat- 
ment should  be  continued  for  several  weeks.  During  conva- 
lescence it  is  advisable  to  give  arsenic  in  the  form  of  Fowler's 
solution  with  the  quinine.  The  following  pill  is  also  useful 
in  the  convalescence  of  malaria  : — 

^  Acid,  arsenosi,   gr.  ss  ; 

Quinin,  sulph.,  gj  ; 

Ferri  pyrophos.,  gr.  xxx  ; 

Pulv.  capsici,  gr.  xv. — M. 
Ft.  in  pil.  ITo.  xxx. 
Sig.— One  tlirice  daily. 

Remittent  Fever. — Absolute  rest.  A  light  diet.  Quinine 
(gr.  XX— xxx)  should  be  given  in  divided  doses  in  the  course 
of  a.  day.  A  laxative  dose  of  calomel  is  a  valuable  adjunct  to 
the  antiperiodic  treatment.  When  the  stomach  is  irritable 
calomel  and  soda  may  be  given  by  the  mouth,  and  the  quinine 
by  the  rectum  or  hypodermically.  In  some  cases  Warburg's 
tincture  is  useful;  half  an  ounce  undiluted  may  be  given,  and 
repeated  in  two  or  three  hours.  After  its  administration  the 
patient  should  be  thoroughly  covered  with  blankets  so  as  to 
favor  free  diaphoresis. 

Pernicious  Malarial  Fever. — From  fifty  to  a  hundred  grains 
of  quinine  must  be  given  before  the  second  paroxysm  occurs. 
It  is  advisable  to  begin  at  once  without  waiting  for  the  inter- 
mission ;  and  twenty  to  thirty  grains  may  be  given  hypoder- 
mically every  two  or  three  hours. 

^   Quininee  sulpli.,  gr.  xl ; 

Sat.  sol.  acid,  tartar.,  TTlxlviij  ; 
Aquse  destil.,  q.  s.  ad  f^ij.— M. 
Sig, — Trixxx=gr,  X. 

When  the  pulse  weakens,  stimulants,  like  whiskey,  ammonia, 
and  strychnine,  should  be  employed.  High  temperature  should 
be  controlled  by  the  external  application  of  cold.  In  the 
algid  form,  heat  should  be  applied  externally,  and  opium 
given  by   the   mouth    or   hypodermically.      In   the  hemor- 


SCAELET    FEVER.  271 

I'hagic  form,  opium  is  also  useful,  and  it  may  be  associated 
with  hsemostatics  like  turpentine,  erigeron,  or  hamamelis. 

Chronic  Malarial  Cachexia. — Iron,  quinine,  and  arsenic  are 
the  remedies  indicated. 

SCARLET  FEVER. 

(Scarlatina.) 

Definition. — An  acute  contagious  disease,  characterized 
by  high  fever,  a  rapid  pulse,  a  punctiform  scarlet  rash,  sore 
throat,  and  an  unusual  tendency  to  nephritis. 

Etiology. — The  specific  poison  of  scarlet  fever  has  not  been 
isolated.  The  contagium  is  usually  carried  through  clothes  or 
other  fomites,  or  in  food  like  milk.  The  disease  can  be 
transmitted  by  direct  inoculation.  The  poison  is  tenacious 
and  of  extreme  vitality ;  infected  clothes,  unused  for  years, 
have  led  to  outbreaks.  The  young  are  especially  predisposed, 
but  not  equally  so.  One  attack  does  not  give  absolute  im- 
munity, but  second  attacks  are  uncommon. 

Pathology. — The  throat  is  inflamed  and  sometimes  ulcer- 
ated ;  the  liver  and  spleen  are  engorged  ;  the  muscles  reveal 
granular  degeneration.  Klein  has  observed  hyperemia  and 
cell-proliferation,  not  only  in  the  throat  and  kidneys,  but 
throughout  the  intestinal  canal.  The  kidneys  frequently  show 
the  lesions  of  hemorrhagic  nephritis,  the  glomeruli  being  espe- 
cially involved.     The  rash  is  rarely  detected  after  death. 

Varieties. — (1)  Simple ;  (2)  anginoid  ;  (3)  malignant. 

Period  of  Incubation. — A  few  hours  to  a  week. 

Symptoms. — The  disease  generally  begins  suddenly,  occa- 
sionally with  a  chill,  but  more  commonly  with  vomiting  or 
convulsions. 

Throat  Symptoms. — Pain  and  difficulty  in  swallowing  ;  ful- 
ness and  tenderness  beneath  the  jaw ;  enlargement  of  the 
lymphatic  glands.  The  tongue  is  at  first  heavily  coated  and 
red  at  the  tip  and  edges ;  in  a  few  days  the  coating  almost 
entirely  disappears,  and  the  papillae  become  bright  red  and 
swollen.  This  appearance  has  given  rise  to  the  term  "  straw- 
berry tongue."  The  pillars,  tonsils,  uvula,  and  pharyngeal 
vault  are  deeply  injected  and  may  reveal  a  punctiform  efflo- 


k. 


272  ACUTE    INFECTIOUS    DISEASES. 

rescence  before  the  rash  develops  on  the  skin.  In  severe  eases 
the  tonsils  may  be  the  seat  of  follicular  inflammation,  or  may 
be  covered  with  false  membrane. 

Eruption. — A  scarlet-red  punctiform  rash  appears  at  the  end 
of  the  first,  or  at  the  beginning  of  the  second  day,  on  the  neck 
and  chest,  and  rapidly  spreads  over  the  entire  body.  It  dis- 
appears on  pressure,  a  white  line  remaining  for  a  second  or  two 
when  the  finger-nail  is  drawn  through  it.  It  may  be  uniform 
or  it  may  occur  in  discrete  patches  surrounded  by  healthy  skin. 
In  five  or  six  days  the  red  color  gradually  fades  and  scaly 
desquamation  soon  follows. 

In  some  cases  the  rash  is  pale  and  scarcely  visible,  in  others 
it  is  slightly  papular  or  vesicular  (scarlatina  miliaris) ;  in  ma- 
lignant cases  it  may  be  petechial. 

Febrile  Symptoms. — The  fever  rises  abruptly,  reaching  its 
maximum  (104°— 105°)  in  twenty-four  or  forty-eight  hours, 
remains  nearly  uniform  for  three  or  four  days,  and  then  falls 
by  lysis.  The  duration  of  the  febrile  period  is  from  seven  to 
nine  days.  The  pulse  is  very  rapid, — out  of  proportion  to  the 
fever ;  the  respirations  are  hurried ;  the  appetite  is  lost ;  the 
bowels  are  constipated ;  and  the  urine  is  scanty,  high-colored, 
and  often  contains  albumin. 

Nervous  Symptoms. — Restlessness,  headache,  insomnia,  de- 
lirium, and  convulsions  may  occur  in  the  course  of  the  disease. 
Convulsions  developing  late  in  the  disease  are  very  significant 
of  uraemia. 

Anginoid  Scarlet  Fever, — This  form  is  characterized  by 
severe  throat  symptoms.  The  tonsils  are  much  swollen  and 
are  often  covered  with  false  membrane.  The  fever  is  high 
and  the  prostration  is  profound.  Ulceration  of  the  throat  fre- 
quently occurs.  Death  may  result  from  exhaustion,  aspiration- 
pneumonia,  or  from  hemorrhage  due  to  ulceration  of  the 
carotid  artery. 

Malignant  Scarlet  Fever. — The  onset  is  abrupt,  with  a  chill, 
vomiting,  or  convulsion  ;  the  fever  is  very  high  (106°-107°)  ; 
the  pulse  is  rapid  and  feeble ;  delirium  sets  in,  and  is  followed 
by  coma.  Death  may  result  before  the  appearance  of  the 
rash,  in  twenty-four  or  forty-eight  hours. 

Complications.    Nephritis. — This  usually  develops  during 


SCARLET    FEVEE.  273 

convalescence,  and  as  it  may  be  unassociated  with  subjective 
symptoms  the  urine  should  be  examined  daily  in  order  to  de- 
tect its  presence ;  in  other  cases  its  advent  is  recognized  by  the 
suppression  of  urine,  by  uraemia,  or  by  dropsy.  Nephritis 
may  be  the  immediate  cause  of  death,  but  more  commonly  it 
ends  in  recovery  ;  it  sometimes  leads  to  chronic  renal  disease. 

Among  other  complications  may  be  mentioned  hyperpyrexia, 
endocarditis,  pericarditis,  pneumonia,  suppuration  of  the  lym- 
phatic glands,  ophthalmia,  inflammation  of  the  middle  ear, 
chorea,  and  a  peculiar  inflammation  of  the  joints  resembling 
rheumatism. 

Diagnosis. — Acute  Tonsillitis  may  resemble  scarlet  fever, 
especially  when  the  former  is  associated  with  an  erythematous 
rash ;  but  in  tonsillitis  there  is  no  history  of  contagion,  the 
pulse  is  proportionate  to  the  fever;  the  rash,  if  present,  is  not 
punctiform;  the  tongue  has  not  the  strawberry  appearance;  and 
there  is  no  tendency  to  nephritis. 

Diphtheria. — The  onset  is  less  abrupt ;  there  is  more  pros- 
tration; false  membrane,  containing  the  Klebs-Loffler  bacillus, 
is  always  present ;  a  cutaneous  rash  is  usually  absent ;  and 
the  tongue  does  not  present  a  strawberry  appearance. 

3Ieasles. — The  sore  throat  is  less  marked  ;  catarrhal  symp- 
toms are  present ;  the  rash  appears  later,  is  papular,  and  forms 
in  crescentic-shaped  patches ;  the  fever  shows  a  decided  remis- 
sion on  the  second  or  third  day  ;  and  the  pulse  is  proportionate 
to  the  fever. 

Rotheln. — This  may  be  difficult  to  distinguish  from  scarla- 
tina, but  the  fever  is  not  so  high,  nor  the  pulse  so  rapid ;  the 
post-cervical  glands  are  more  swollen ;  there  is  no  tendency  to 
nephritis ;  and  the  rash  is  not  punctiform. 

Accidental  Rashes. — Certain  drugs  like  belladonna,  quinine, 
and  copaiba,  and  certain  foods,  like  crabs  and  oysters,  may 
produce  a  rash  like  that  of  scarlet  fever,  but  it  is  not  puncti- 
form, and  is  not  associated  with  high  fever,  sore  throaty  and 
rapid  pulse. 

Prognosis. — Always  guarded.  The  mortality  varies  in 
different  epidemics  from  5  to  40  per  cent. 

Treatment.  —  Isolation.  Absolute  rest.  Liquid  diet. 
The  surface  of  the  body  should  be  anointed  two  or  three  times 
18 


274  ACUTE    INFECTIOUS    DISEASES. 

dail}^  with  cold  cream,  cocoa-butter,  or  carbolized  vaseline. 
The  patient  should  be  encouraged  to  drink  water  or  lemonade 
freely.  Gastric  irritability  may  call  for  small  doses  of  calo- 
mel, bismuth,  or  nitrate  of  silver.  When  the  ston)ach  is 
retentive,  the  tincture  of  the  chloride  of  iron  may  be  given 
with  small  doses  of  dilute  hydrochloric  acid,  thus  : — 

'^.  Tinct.  ferri  chlor.,  f^ij  ; 
Acid,  hydrochlor.dil.,  fgj  ; 
Syr.  limonis,  f  3j  ; 
Aquae,  q.  s.  ad  f  ^iij.— M. 
Sig. — Teaspoonful  in  water  every  two  or  three  hours. 

The  fauces  and  pharynx  should  be  kept  clean  by  antiseptic 
washes  or  sprays,  such  as  Dobell's  solution,  dilute  peroxide  of 
hydrogen,  or  dilute  listerine. 

Cerebral  symptoms  may  be  controlled  by  bromide  of  potas- 
sium, chloral,  by  an  ice-bag  to  the  head,  or,  when  due  to 
fever ^  by  the  cold  bath. 

High  fever  is  best  treated  by  sponging,  by  the  cold  pack, 
or  by  the  graduated  cold  bath. 

The  urine  should  be  examined  daily  for  evidence  of  ne- 
phritis, and,  if  the  latter  arises,  the  diet  should  be  cut  down 
to  skimmed  milk  or  buttermilk  ;  dry  cups  may  be  applied  to 
the  loins ;  the  bowels  kept  active  by  Epsom  or  Rochelle  salt ; 
and  diaphoresis  encouraged  by  small  doses  of  jaborandi. 

Cardiac  weakness  will  call  for  stimulants  like  alcohol,  am- 
monia, strychnine,  and  digitalis. 

Convalescence  should  be  guarded  and  protracted. 

MEASLES. 

(Rubeola,  Morbilli.) 

Definition. — An  acute  contagious  disease,  characterized 
by  catarrh  of  the  respiratory  tract,  moderate  fever,  and  a  red 
papular  eruption,  which  appears  on  the  fourth  day  and  termi- 
nates in  two  or  three  days  by  branny  desquamation. 

Etiology. — Measles  is  highly  contagious,  and  the  poison 
may  be  transmitted  through  clothes  and  other  fomites.  The 
contagium  is  apparently  associated  with  the  nasal  and  bron- 
chial secretion,   but   it  has   not   been  isolated.     It  is   most 


MEASLES.  275 

commonly  observed  in  children,  but  unprotected  adults  are 
very  liable  to  be  attacked.  It  is  essentially  an  epidemic  dis- 
ease, but  now  and  then  sporadic  cases  occur.  One  attack  is 
fairly  protective,  but  does  not  give  absolute  immunity. 

Pathology. — The  lesions  consist  in  catarrh  of  the  entire 
respiratory  tract.  Gastro-intestinal  catarrh  is  not  uncommon. 
In  fatal  cases  such  complications  as  capillary  bronchitis, 
catarrhal  pneumonia,  and  pulmonary  collapse  are  frequently 
observed. 

Period  of  Incubation. — About  two  weeks. 

Symptoms.  Prodromes. — Chilliness,  coryza,  watering  of  the 
eyes,  photophobia,  cough,  and  drowsiness. 

The  Fever. — The  temperature  rises  rapidly  to  102°  or  103°, 
but  on  the  second  day  there  is  a  decided  remission  which 
continues  until  the  fourth  day,  when  the  eruption  appears  ;  at 
this  time  it  again  rapidly  runs  up  to,  or  beyond,  its  original 
height  where  it  remains  for  two  or  three  days  and  then  falls 
by  crisis. 

The  Catarrh. — Redness  of  the  conjunctivae,  lachrymation, 
sneezing,  hoarseness,  cough,  and  expectoration.  There  may 
be  vomiting  or  diarrhoea. 

The  Eruption. — This  appears  about  the  fourth  day  on  the 
face,  and  rapidly  spreads  over  the  entire  body.  It  is  com- 
posed of  small,  dark-red,  velvety  papules,  which  form  groups 
having  crescentic  borders.  In  two  or  three  days  the  eruption 
begins  to  fade,  and  branny  desquamation  soon  follows. 

Minute  bluish-white  specks  surrounded  by  a  red  areola 
may  be  seen  on  the  mucous  membrane  of  the  cheeks  and 
lips  one  or  two  days  before  the  skin  eruption  appears 
(Koplik's  sign). 

Malignant,  or  Hemorrhagic  Measles. — This  form  occurs 
under  bad  hygienic  conditions,  and  is  characterized  by  a  pete- 
chial rash,  by  hemorrhages  from  the  mucous  membranes,  and 
by  profound  prostration. 

Complications  and  Sequels.  —  Capillary  bronchitis, 
catarrhal  pneumonia,  tuberculosis,  otitis,  gastro-intestinal 
catarrh,  caucrum  oris,  and  paralysis. 

Diagnosis.  Rbtheln. — Prodromes  are  often  absent ;  fever 
and  catarrh  are  slight;    sore  throat  is  paarked.      The  rash 


I 


276  ACUTE   INFECTIOUS    DISEASES. 

appears  on  the  iirst  or  second  day  as  a  diffuse  red  blush,  or 
as  small  pale-red  spots  which  do  not  form  crescentic-shaped 
patches ;  desquamation  is  scarcely  noticeable. 

Scarlet  Fever. — The  fever  is  high  and  lacks  the  pre-eruptive 
remission ;  sore  throat  is  present  instead  of  general  catarrh ; 
the  eruption  appears  on  the  first  or  second  day  as  a  diffuse 
punctiform  rash ;  the  pulse  is  out  of  proportion  to  the  fever ; 
and  there  is  much  greater  tendency  to  nephritis. 

Peognosis. — Guardedly  favorable.  Complications  are  apt 
to  occur  and  render  the  prognosis  grave. 

Treatment. — Isolation.  A  darkened  well- ventilated  room 
absolute  rest.  A  liquid  diet.  Such  refrigerant  remedies  as 
sweet  spirits  of  nitre  and  liquor  ammonise  acetatis  are  indicated 
and  may  be  combined  with  a  little  aconite. 

]^   Spt.  sether.  nitrosi,  ff  j  ; 

Liq.  amnion,  acetatis,  q.  s.  ad  f^iij. — M. 
Sig.^ — A  teaspoon  ful  every  two  hours. 

When  the  bronchitis  is  severe  it  is  advisable  to  envelop 
the  chest  with  a  cotton  jacket,  and  to  administer  expectorant 
with  sedatives  like  paregoric. 

R     Liq.  potass,  citrat.,  ff  iss ; 
Tinct.  opii  camph.,  f^iij  ; 
Syr.  ipecac,  f^ij  ; 
Syr.  acaciae,  f^ss ; 
Aquae,  q.  s.  ad  f^iij. — M. 
Sig. — A  dessertspoonful  every  two  hours  for  a  child  of  five  years. 

Gastric  irritability  should  be  relieved  by  small  doses  of  bis- 
muth or  by  calomel  and  soda.  During  desquamation  the  skin 
should  be  anointed  two  or  three  times  daily.  High  fever  is 
best  controlled  by  sponging  with  tepid  water.  During  con- 
valescence nutrients  like  cod-liver  oil  and  malt,  and  tonics  like 
iron,  quinine,  and  strychnine  are  indicated. 

KOTHELN. 

(Rubella,  German  Measles,  Epidemic  Roseola.) 
Definition. — An  acute  contagious  disease  resembling  both 
scarlet  fever  and  measles,  but  differing  from  these  in  its  short 
course,  slight  fever,  and  freedom  from  sequelee. 

Etiology. — The  disease  is  highly  contagious,  and  the 
poison  may  be  carried  on  clothes  or  other  fomites.     It  gener- 


SMALLPOX.  277 

ally  occurs  in  epidemics,  but  sporadic  cases  are  not  uncommon. 
It  is  most  frequently  observed  in  children,  but  unprotected 
adults  are  not  exempt.  One  attack  usually  protects  from 
another,  but  not  from  measles  or  scarlet  fever. 

Period  of  Incubation. — About  two  weeks. 

Symptoms. —  Prodromes  are  slight,  or  altogether  absent. 
The  disease  begins  with  drowsiness,  slight  fever,  and  sore 
throat.  The  eruption  appears  on  the  first  or  second  day,  and 
varies  considerably  in  its  character.  In  some  cases  the  rash 
is  composed  of  pale-red,  scarcely  elevated  papules,  which  a,re 
more  or  less  discrete  {rubella  morbilliforme) ;  in  others  the  rash 
is  bright  red  and  diifuse  like  that  of  scarlet  fever  (^rubella  scar- 
latinifor^me).  It  begins  on  the  face  and  rapidly  spreads  over 
the  entire  body,  but  it  fades  so  rapidly  that  the  face  may  be 
clear  before  the  extremities  are  affected.  Slight  desquamation 
frequently  follows,  though  it  is  often  absent.  Apart  from  the 
sore  throat,  the  catarrhal  symptoms  are  slight.  The  super- 
ficial cervical  and  posterior  auricular  glands  are  more  swollen 
than  in  measles. 

The  duration  is  from  three  to  five  days. 

Prognosis. — Good.     Complications  are  rare. 

Treatment. — Rest.  Liquid  diet.  Refrigerants.  Spong- 
ing with  tepid  water. 

SMAI.LPOX. 

(Variola.) 

Definition.— An  acute  contagious  disease,  characterized  by 
vomiting ;  lumbar  pains;  an  eruption  which  is  at  first  papular, 
then  vesicular,  and  finally  pustular ;  and  by  fever  which  is 
marked  by  a  distinct  remission  beginning  with  the  advent  of 
the  eruption,  and  lasting  until  the  latter  becomes  pustular. 

Etiology. — The  poison  of  smallpox  is  extremely  tenacious ; 
it  may  remain  latent  in  clothes  or  other  fomites  for  a  long  time, 
and  then  be  capable  of  exciting  the  disease.  The  virulent 
principle  is  doubtless  contained  in  the  pustules  and  in  all  the 
excretions  of  the  body,  but  it  has  not  been  isolated.  Unless 
protected  by  vaccination  or  a  previous  attack,  nearly  every  one 
is  susceptible,  from  the  aged  to  the  child  in  utero.  The  colored 
race  seem  especially  predisposed. 


278  ACUTE   INFECTIOUS   DISEASES. 

Pathology. — The  eruption  consists  in  an  infiltration  of 
cells  into  the  rete  mucosum  or  into  the  true  skin_.  The  cells 
ultimately  undergo  liquefaction-necrosis,  when  suppuration 
soon  follows.  Genuine  pocks  are  frequently  found  in  the 
moUth,  oesophagus,  and  larynx,  and  rarely  in  the  stomach, 
trachea,  and  bronchi.  The  spleen  is  engorged.  The  organs 
and  muscles  reveal  fatty  and  parenchymatous  degeneration. 

Varieties. — Discrete ;  confluent ;   malignant ;  varioloid. 

Fig.  21. 


Temperature  Curve  in  Smallpox. 

Symptoms.  Discrete  Smallpox.  —  The  disease  usually 
begins  with  a  chill  or  series  of  chills,  followed  by  vomiting  and 
intense  lumbar  pains.  The  fever  rises  rapidly,  reaching  its 
maximum  (104°-105°)  in  forty-eight  hours,  and  continues 
high  until  the  third  or  fourth  day,  when  it  falls  several  degrees  ; 
this  remission  lasts  until  the  seventh  or  eighth  day, — that  is, 
the  time  of  pustulation, — when  it  again  rises.  The  secondary 
or  suppurative  fever  shows  marked  fluctuations  ;  its  height  is 
proportionate  to  the  number  of  pustules  ;  and  it  falls  by  lysis 
about  the  eighteenth  day  of  the  disease.  The  pulse  is  full  and 
rapid  (120-140)  ;  the  breathing  is  hurried;  the  skin  is  dry ; 
the  bowels  are  usually  constipated,  though  diarrhoea  is  not  un- 
common ;  and  the  urine  is  scanty  and  frequently  albuminous. 

The  Eruption. — About  the  third  or  fourth  day  small  red 
spots  are  noticed  on  the  forehead,  face,  and  wrists ;  these  are 
rapidly  converted  into  smooth  round  papules  which  feel  like 
shot  under  the  skin.  The  eruption  rapidly  spreads  over  the 
entire  body.  About  the  third  day  the  papules  are  converted 
into  clear  vesicles,  which  present  a  depression  or  umbilication 


SMALLPOX.  279 

at  their  summit.  They  are  also  loculated,  i.  e.  divided  into 
compartments  by  fibrinous  partitions,  so  that  when  pricked 
with  a  needle  all  of  the  contained  fluid  does  not  escape.  In 
two  or  three  days  the  clear  fluid  becomes  turbid  and  the 
vesicles  are  gradually  converted  into  pustules.  The  latter 
soon  lose  the  umbilicated  appearance.  Between  the  lesions 
the  skin  is  oedematous,  so  that  the  body  is  swollen  and  the 
features  are  unrecognizable.  Tn  three  days  more  the  pustules 
dry  up,  or  break  and  form  soft  yellow  crusts  which  exhale  a 
peculiar,  ofi^ensive  odor ;  they  adhere  to  the  skin  for  a  week  or 
more.  When  the  scabs  fall  off,  scars,  or  pock-marks  generally 
remain,  constituting  a  permanent  deformity. 

At  the  beginning  of  the  disease,  before  the  true  variolous 
eruption  appears,  either  a  red  blush  or  a  macular  rash  is  often 
observed  on  the  inner  side  of  the  arms  and  thighs. 

Confluent  Smallpox. — The  papules  are  abundant,  and  soon 
coalesce.  The  extremities  are  swollen  and  painful.  The 
secondary  fever  is  very  high  and  irregular.  True  pocks  nearly 
always  develop  in  the  air-passages  and  give  rise  to  a  copious 
fetid  discharge  from  the  nose  and  throat,  to  hoarseness,  and  to 
cough.  Delirium,  stupor,  and  subsultuB  are  frequent  symp- 
toms. If  the  patient  recovers,  it  is  after  a  tedious  con- 
valescence, with  great  facial  disfigurement,  and  often  with 
defective  vision  and  hearing. 

Malignant  Smallpox. — In  some  cases  the  disease  is  ushered 
in  with  high  fever,  lumbar  pains,  and  great  prostration.  Soon 
ecchyuioses  appear  on  the  skin ;  bleeding  from  the  mucous 
membranes  follows  ;  and  death  results  before  a  true  variolous 
rash  appears.  In  other  cases  the  disease  advances  like  or- 
dinary smallpox  up  to  the  pustular  stage  ;  then  the  pustules 
become  efiiised  with  blood,  and  bleeding  from  the  mucous 
membi'ane  follows.     This  form  is  also  very  fatal. 

Varioloid. — This  is  modified  smallpox  occurring  in  one  who 
has  been  partially  protected  by  previous  vaccination.  The 
symptoms  are  mild ;  the  eruption  resembles  that  of  common 
smallpox,  but  is  usually  very  scant;  secondary  fever  is 
absent. 

Complications    and    Sequels. — Broncho-pneumonia; 


280  ACUTE   INFECTIOUS   DISEASES. 

pleurisy ;  inflammations  of  the  eye  (keratitis,  iritis,  conjunc- 
tivitis) ;  otitis ;  arthritis ;  and  boils. 

Diagnosis.  Varicella. — The  symptoms  are  milder ;  pro- 
dromes are  generally  absent ;  the  eruption  appears  earlier,  is 
more  superficial,  lacks  an  inflammatory  areola,  is  more  abun- 
dant on  the  trunk  than  the  face,  and  is  rarely  umbilicated. 

Secondary  Syphilis. — The  history ;  the  absence  of  fever ; 
the  symmetrical  distribution  of  the  eruption ;  its  dark- 
coppery  color;  its  polymorphous  character  (papules,  vesicles, 
and  pustules  associated  in  a  limited  area)  ;  and  the  absence 
of  itching  will  indicate  syphilis. 

Prognosis. — This  depends  upon  the  virulence  of  the  epi- 
demic, the  degree  of  protection  by  vaccination,  and  the  amount 
of  the  eruption.  In  discrete  cases,  it  is  generally  favorable  ; 
in  the  confluent,  grave  ;  in  the  malignant,  almost  hopeless. 

Treatment. — The  prophylactic  treatment  consists  in  vac- 
cination. 

The  Attach. — Isolation.  Every  precaution  must  be  taken  to 
prevent  the  spread  of  the  disease.  The  other  members  of  the 
family  should  be  vaccinated  at  once.  The  room  should  be 
cool  and  well  ventilated.  The  diet  must  be  liquid  or  semi- 
liquid,  and  may  consist  of  milk,  meat  broths,  eggs,  etc.  The  free 
use  of  water,  lemonade,  or  soda-water  should  be  encouraged. 
The  intense  lumbar  pains  should  be  relieved  by  opium  and  the 
application  of  hot- water  bags.  Gastric  irritability  may  call 
for  bismuth  or  calomel  and  soda.  The  naso-pharynx  should 
be  kept  clean  by  antiseptic  washes  and  sprays,  and  Dobell's 
solution,  dilute  listerine,  or  dilute  peroxide  of  hydrogen  may 
be  used  for  this  purpose.  The  eyes  must  be  kept  clean  by 
being  washed  several  times  a  day  with  a  saturated  solution  of 
boric  acid.  Stimulants  are  often  indicated.  High  fever  may 
be  controlled  by  antipyrin  or  phenacetin,  or  by  the  cold  pack 
or  cold  bath. 

The  prevention  of  Pitting. — The  room  should  be  darkened, 
and  the  exposed  parts  covered  with  cloths  soaked  in  dilute 
carbolic  acid  or  bichloride  of  mercury,  or  with  masks  upon 
which  has  been  spread  some  simple  ointment,  as  one  of  mercury 
or  of  zinc.  Unfortunately,  when  the  lesions  are  deeply  situ- 
ated there  is  no  means  of  preventing  pitting.  The  separation 
of  the  scabs  may  be  facilitated  by  the  use  of  warm  baths. 


VARICELLA — VACCINIA.  281 

VARICELLA. 

(Chicken-pox.) 

Definition. — An  acute  contagious  disease  of  short  duration, 
characterized  by  slight  fever  and  a  discrete  vesicular  eruption, 
which  disappears  in  two  or  three  days  by  desiccation. 

Etiology. — The  disease  occurs  sporadically  and  epidemi- 
cally. It  is  observed  chiefly  in  children,  but  adults  are  not 
exempt.  One  attack  usually  protects  from  others.  It  bears 
no  relation  to  smallpox. 

Period  of  Incubation. — One  to  two  weeks. 

Symptoms. — Slight  fever  and  the  appearance  of  a  vesicular 
eruption  within  the  first  twenty- four  hours.  The  vesicles  ap- 
pear in  crops  over  two  or  three  days ;  they  are  superficial, 
rarely  umbilicated,  and  lack  the  red  areola  which  is  seen 
around  the  vesicles  of  variola.  They  rarely  become  pustular, 
and  are  only  occasionally  followed  by  scars.  The  duration 
is  about  a  week.  In  rare  instances  gangrene  occurs  around 
the  vesicles  or  in  other  parts  (varicella  gangrenosa). 

DiAiG^ONSis.  Smallpox. — The  slight  fever  ;  the  absence  of 
lumbar  pains ;  the  early  appearance  of  the  vesicles,  their 
marked  variation  in  size,  and  their  greater  intensity  on  the 
trunk ;  and  the  absence  of  umbilication  and  red  areola  will 
serve  to  distinguish  varicella  from  smallpox. 

Prognosis. — Always  favorable. 

Treatment. — Rest  in  bed.  A  light  diet.  The  application 
of  some  sedative  lotion  or  ointment  to  allay  itching  and  to  pre- 
vent scratching. 

VACCINIA. 

(Vaccination,  Co^w-pox.) 

Definition. — A  general  disease  with  a  local  manifestation 
resembling  the  pock  of  variola,  and  acquired  by  inoculation 
with  the  virus  of  cow-pox. 

History  and  Object. — The  value  of  vaccination  as  a 
means  of  protection  against  smallpox  was  first  made  knowai 
to  the  world  in  a  paper  published  by  Edward  Jenner  in  1798. 


282  ACUTE   INFECTIOUS   DISEASES. 

Recent  vaccination  gives  almost  complete  immunity  from 
variola ;  the  mortality  of  smallpox  acquired  after  vaccination 
is  almost  inversely  proportionate  to  the  number  of  true  vac- 
cine scars. 

Etiology. — Vaccinia  is  induced  by  inoculating  the  arm 
with  fresh  virus  obtained  from  the  udder  of  a  calf  suffering 
from  cow-pox  (bovine  virus),  or  from  the  vesicle  of  a  patient 
who  has  already  been  vaccinated  (humanized  virus).  The 
former  is  preferable  on  account  of  the  readiness  with  which  the 
fresh  article  can  be  obtained,  and  on  account  of  its  freedom 
from  other  poisons,  like  syphilis.  It  has  been  shown  that 
the  addition  of  glycerin  to  vaccine  lymph  serves  to  preserve 
it,  and  to  free  it  from  pathogenic  bacteria. 

Time  or  Performance. — The  first  vaccination  should  be 
made  about  the  third  month,  the  second  at  the  seventh  year, 
and  the  third  at  puberty.  It  should  always  be  repeated  when 
smallpox  is  prevalent. 

Performance  of  Vaccination. — The  arm  should  be  ren- 
dered aseptic,  and  the  skin  scratched  with  a  lancet  or  with  the 
ivory  point  containing  the  lymph  until  red  serum  begins  to 
ooze,  when  the  moistened  virus  should  be  carefully  worked  in. 
The  spot  must  be  carefully  protected  from  the  clothes  until 
thoroughly  dry. 

Symptoms. — About  the  second  or  third  day  after  the  opera- 
tion a  papule  surrounded  by  a  red  areola  forms  at  the  seat  of 
inoculation.  In  two  or  three  days  the  papule  is  converted 
into  a  clear  vesiclcj  which  is  umbilicated  at  its  summit ;  the 
surrounding  tissues  are  red,  tender,  and  considerably  infil- 
trated. About  the  seventh  or  eighth  day  the  vesicle  is  per- 
fected and  its  contents  become  turbid ;  this  lasts  until  the 
twelfth  day,  when  it  dries  uj)  and  forms  a  scab,  which  sepa- 
rates during  the  third  week  and  leaves  behind  a  pitted 
scar.  During  the  course  of  the  eruption  there  are  slight 
fever,  malaise,  restlessness,  and  enlargement  of  the  axillary 
glands. 

Complications. — Erysipelas,  abscess,  and  various  cutaneous 
eruptions.  Syphilis  has  occasionally  been  transmitted  through 
humanized  virus. 


ERYSIPELAS.  283 

ERYSIPELAS. 

(St.  Anthony's  Fire.) 

Definition.  —  An  acute  contagious  disease  excited  by- 
streptococci,  and  characterized  by  a  peculiar  inflammation  of 
the  skin  and  subcutaneous  tissue,  irregular  fever,  and  a  ten- 
dency to  relapse. 

Etiology. — The  disease  is  somewhat  contagious  and  the 
poison  can  be  carried  in  fomites.  Certain  families  and  certain 
individuals  seem  particularly  predisposed.  Puerperal  women 
and  wounded  persons  are  very  susceptible.  Diseases  which 
lower  the  vitality,  especially  Bright's  disease,  predispose.  One 
attack  does  not  protect  against  a  recurrence,  but  rather  favors 
it.  Erysipelas  was  formerly  divided  into  traumatic  and  idio- 
pathic varieties  ;  but  the  two  are  identical,  and  it  is  probable 
that  in  those  cases  in  which  there  is  no  conspicuous  wound 
there  is  a  slight  abrasion  through  which  the  poison  gains  ad- 
mittance. 

The  exciting  cause  is  doubtless  the  streptococcus  pyogenes. 

Pathology. — Erysipelas  most  frequently  manifests  itself 
on  the  face.  The  part  is  bright  red  in  color,  swollen,  in- 
durated, and  sharply  circumscribed.  The  various  strata  of  the 
skin  are  infiltrated  with  serum,  and  leucocytes  and  streptococci 
are  found  in  the  lymph-spaces.  In  severe  cases  the  inflam- 
matory products  are  converted  into  pus,  and  abscesses  form. 

Period  of  Incubation. — Three  to  seven  days. 

Symptoms. — Prodromes  are  sometimes  present,  and  consist 
of  slight  fever,  chilliness,  malaise,  tingling  of  the  part  to  be 
affected,  and  sometimes  enlargement  of  neighboring  lymphatic 
glands.  In  many  cases  the  disease  is  ushered  in  suddenly 
with  a  chill,  followed  by  pain  in  the  head  and  limbs  and  a 
high,  irregular  fever.  The  temperature  may  reach  103°  or 
104°  in  twelve  or  twenty-four  hours.  The  pulse  is  full  and 
rapid ;  the  tongue  is  heavily  coated  ;  the  appetite  is  lost ;  the 
bowels  are  constipated ;  and  the  urine  is  scanty  and  often 
slightly  albuminous. 

Local  Phenomena. — The  inflammation  usually  begins  in  the 
neighborhood  of  the  nose,  and  spreads  upward  and  laterally  over 


284  ACUTE   INFECTIOUS   DISEASES. 

the  head  to  the  neck,  where  it  frequently  stops.  The  affected 
part  has  a  crimson  hue ;  it  is  swollen  and  tense,  and  frequently 
ends  in  a  sharply-defined  ridge,  beyond  which,  however,  pro- 
jections can  be  felt  advancing  into  the  subcutaneous  tissue. 
The  surface  of  the  inflamed  patch  is  at  first  smooth  and  glazed, 
but  later  it  is  covered  with  minute  vesicles  or  blebs.  The  patient 
complains  of  burning  and  tingling  ;  the  surrounding  parts  are 
extremely  oedematous,  so  that  the  features  may  be  scarcely 
recognizable.  In  four  or  five  days  the  redness  begins  to  fade 
and  the  swelling  to  subside ;  desquamation  follows ;  the  general 
symptoms  improve;  and  the  fever  falls  by  crisis.  The  average 
duration  is  from  a  week  to  ten  days.  Relapses  are  extremely 
common. 

Erysipelas  Ambulans. — Sometimes  the  inflammation  disap- 
pears in  one  place  and  reappears  in  another,  and  so  continues 
indefinitely.  In  such  cases  typhoid  symptoms,  such  as  mut- 
tering delirium,  a  brown,  fissured  tongue,  and  subsultus  ten- 
dinum,  develop. 

Complications.  —  Inflammation  of  serous  membranes 
(pericarditis,  pleuritis,  meningitis),  oedema  of  the  larynx,  ne- 
phritis, hyperpyrexia,  ulcerative  endocarditis,  and  septicaemia. 

Diagnosis.  Erythema.  —  The  absence  of  high  fever,  of 
marked  swelling,  and  of  an  abrupt  ridge  will  serve  to  dis- 
tinguish erythema  from  erysipelas. 

Aeute  Eczema. — The  swelling  is  less  marked  ;  the  itching  is 
intense ;  the  swelMng  and  redness  are  not  circumscribed,  but 
shade  gradually  into  healthy  tissue  ;  and  there  is  no  fever. 

Peognosis. — In  the  robust  the  prognosis  is  favorable.  In 
the  old,  in  alcoholic  subjects,  and  in  those  suffering  from 
chronic  nephritis,  the  prognosis  must  be  guarded.  Ambulatory 
erysipelas  may  kill  by  exhaustion. 

Teeatment. — Isolation  ;  absolute  rest ;  a  nutritious  diet. 
It  is  well  to  begin  the  treatment  with  a  saline  or  mercurial 
laxative.  The  tincture  of  the  chloride  of  iron  seems  to  exert 
a  beneficial  influence;  it  may  be  given  in  doses  of  twenty 
drops  every  two  hours.  Quinine  (gr.  v  thrice  daily)  is  also 
useful.  When  there  is  much  restlessness  and  insomnia,  bro- 
mide of  potassium,  chloral,  or  opium  may  be  administered. 

Local  Treatment. — One  of  the  following  applications  may  be 


YELLOW    FEVER.  285 

employed :  Cloths  wrung  out  in  a  solution  of  bichloride  of 
mercury  (1-5000),  or  in  a  saturated  solution  of  boric  acid,  or  in 
lead-water  and  laudanum  ;  a  dusting  powder  of  starch  and 
oxide  of  zinc  ;  or  an  ointment  of  ichthyol. 

^  Plumbi  acetatis,  ^j  ; 
Tinct.  opii,  f  3J  ; 
Aqua3,  q.  s.  Oj. — M. 
Sig. — Shake  well  and  apply  on  Hut. 

Or— 

!^  Ichthyol,  §ss ; 
Vaselin.,  |ij, — M. 
Sig. — Spread  thickly  on  lint  kud  apply  to  the  affected  part. 

The  injection  of  antiseptic  remedies  around  the  inflammatory 
patch,  with  the  view  of  preventing  its  spread,  is  very  painful 
and  seldom  efficacious. 

YELLOW  FEVER. 

Definition. — An  acute  infectious  disease,  characterized  by 
jaundice,  epigastric  tenderness,  vomiting,  hemorrhages,  and  a 
febrile  course  consisting  of  two  paroxysms. 

Etiology. — A  hot  climate  and  a  warm  season,  salt  water, 
bad  drainage,  and  overcrowding  favor  the  development  of 
epidemics.  The  disease  is  not  distinctly  contagious ;  the 
poison  probably  undergoes  some  changes  outside  of  the  body, 
and  is  carried  through  the  atmosphere,  clothes,  or  other 
fomites.  The  colored  race  are  less  susceptible  than  the 
white.  Strangers  in  an  infected  district  are  more  liable  to  be 
attacked  than  residents.  One  attack  usually  confers  immu- 
nity from  others.  The  exciting  cause  is  probably  the  bacillus 
icteroidis,  a  fine,  motile,  ciliated  rod,  recently  described  by 
Sanarelli. 

Pathology. — The  tissues  are  stained  yellow  by  disin- 
tegrated blood  (hsematogenous  jaundice).  The  liver  is  pale 
and  is  the  seat  of  extensive  fatty  degeneration.  The  gastric 
mucous  membrane  is  swollen,  congested,  and  frequently  ecchy- 
mosed.  The  spleen  is  not  enlarged.  The  heart  is  pale  and 
flabby.  The  kidneys  are  generally  the  seat  of  parenchymatous 
inflammation. 


286  ACUTE    INFECTIOUS   DISEASES. 

Period  of  Incubation. — A  few  hours  to  a  week. 

Symptoms.  First  Stage. — The  disease  begins  with  a  chill, 
followed  by  pain  in  the  head,  back,  and  limbs.  The  tempera- 
ture rises  rapidly  until  it  reaches  its  maximum  (103°-105°). 
The  pulse,  however,  is  not  proportionately  rapid,  and  often 
remains  at  70  or  80  per  minute.  The  face  is  flushed,  slightly 
icteroid,  the  conjunctivae  are  injected,  and  the  pupils  small ; 
the  tongue  is  coated,  the  epigastrium  is  tender,  the  stomach 
is  irritable  and  unretentive  ;  the  bowels  are  constipated ;  and 
the  urine  is  scanty  and  albuminous.  This  stage  lasts  from  a 
few  hours  to  several  days,  and  is  followed  by  a  marked  fall 
in  the  temperature  and  an  improvement  in  the  general  symp- 
toms (stage  of  remission).  At  this  time  convalescence  may 
begin,  or  the  patient  may  pass  into  the  second  febrile  par- 
oxysm. 

Second  Stage. — The  fever  rises  to  its  original  height ;  the 
skin  becomes  yellow  ;  vomiting  is  persistent,  and  the  ejected 
material  may  contain  dark  blood  ("  black  vomit").  Hemor- 
rhages sometimes  occur  from  other  mucous  membranes. 
The  pulse  is  rapid,  though  not  proportionate  to  the  fever. 
The  urine  becomes  very  scanty  and  contains  albumin  and 
casts.  The  mind  often  remains  clear  until  near  the  close. 
Death  frequently  results  from  exhaustion  or  uraemia,  though 
recovery  may  follow  the  gravest  symptoms. 

Duration. — From  a  few  hours  to  a  week. 

Diagnosis.  Dengue. — This  disease  does  not  exhibit  a 
slow  pulse  with  the  rising  temperature,  albuminuria,  jaundice, 
or  black  vomit. 

Acute  Yelloio  Atrophy  of  the  Liver. — The  rapid  pulse,  the 
diminution  in  the  size  of  the  liver,  the  slight  fever,  the 
marked  cerebral  symptoms,  and  the  presence  of  leucin  and 
ty rosin  in  the  urine  will  indicate  acute  yellow  atrophy. 

Remittent  Fever. — This  may  be  distinguished  by  the  enlarge- 
ment of  the  spleen,  the  multiple  remissions,  the  presence  in  the 
blood  of  hsematozoa  of  Laveran,  and  by  the  absence  of  black 
vomit. 

Prognosis. — Always  grave.  The  average  mortality  in 
different  epidemics  is  from  twenty  to  seventy  per  cent.     In 


ACUTE    GENERAL    TUBERCULOSIS.  287 

individual  cases,  high  fever,  severe  cerebral  symptoms,  black 
vomit,  and  suppression  of  urine  are  unfavorable  features. 

Treatment. — Absolute  rest.  A  cool,  well- ventilated  room. 
A  liquid  diet.  The  pains  in  the  back  and  limbs  may  be  re- 
lieved by  hot- water  bags  and  the  administration  of  morphine. 
For  the  gastric  irritability  a  mustard  plaster  may  be  applied 
to  the  epigastrium,  and  cracked  ice,  iced  champagne,  carbolic 
acid,  or  small  doses  of  calomel  may  be  given  internally.  Stim- 
ulants are  frequently  indicated.  Quinine  may  be  given  by 
the  rectum.  High  fever  is  best  controlled  by  the  external 
application  of  cold.  The  black  vomit  results  from  blood- 
dyscrasia,  and  while  such  remedies  as  gallic  acid,  Monsel's 
solution,  ergot,  and  turpentine  are  recommended,  they  usually 
prove  useless. 

ACUTE  GENERAL  TUBERCULOSIS. 

(Acute  Miliary  Tuberculosis.) 

Definition. — An  acute  infectious  disease  excited  by  the 
tubercle  bacillus,  and  characterized  anatomically  by  the 
simultaneous  formation  of  miliary  tubercles  in  many  parts  of 
the  body. 

Etiology. — The  disease  usually  develops  in  early  adult 
life.  Certain  infectious  diseases  like  measles,  whooping-cough, 
and  typhoid  fever  seem  to  predispose.  General  tuberculosis 
is  almost  always  secondary  to  local  tuberculosis — pulmonary 
phthisis  or  a  scrofulous  lymphatic  gland.  The  bacilli  are 
probably  disseminated  by  the  veins. 

Pathology. — All  the  organs  may  be  uniformly  infiltrated 
with  discrete  tubercles,  but  more  commonly  certain  organs, 
like  the  brain  and  lungs,  are  more  affected  than  others. 

Symptoms. — Debility ;  loss  of  flesh  and  strength  ;  fever 
moderately  high (102°-1 04°),  irregular,  and  marked  by  evening 
exacerbations  and  morning  remissions ;  cough ;  hurried  respi- 
rations ;  a  brown,  fissured  tongue ;  a  weak,  rapid  pulse ;  en- 
largement of  the  spleen ;  delirium ;  subsultus  tendinum  ;  and 
stupor. 

Tubercle  bacilli  are  rarely  found  in  the  expectoration  or  in 
the  blood.  ^ 


288 


ACUTE    INFECTIOUS    DISEASES. 


The  duration  is  from  two  to  four  weeks. 

When  the  lungs  are  chiefly  affected  there  are :  Dyspnoea, 
marked  cough,  muco-purulent  and  bloody  expectoration, 
cyanosis,  sibilant  and  subcrepitant  rales,  and  perhaps  areas 
over  which  bronchial  breathing  is  detected. 

When  the  meninges  are  chiefly  affected  there  are :  Intense 
headache,  convulsive  seizures,  photophobia,  delirium,  facial 
palsies,  stupor,  coma,  and  Cheyne-Stokes  breathing.  Tubercles 
may  be  detected  on  the  retina. 

When  the  intestines  and  peritoneum  are  affected  there  are  : 
Pain,  tenderness,  abdominal  distention,  and  diarrhoea. 

Diagnosis. — The  disease  closely  resembles  typhoid  fever, 
and  there  is  no  doubt  that  the  mortality  of  the  latter  is  en- 
hanced by  included  cases  of  unsuspected  general  tuberculosis. 

The  following  table  will  indicate  the  points  of  distinction  : — 


Typhoid  Eever. 

Epistaxis  common. 
The  temperature  rises  gradually, 
and  runs  a  regular  course. 

Diarrhoea  is  frequent. 

All  eruption  is  generally  present. 

No  tubercles  on  the  retina. 

Kespirations  are  hurried. 

Facial  palsies  are  rare. 

Widal  reaction  is  present. 


Acute  General  Tuber- 
culosis. 

Infrequent. 

The  temperature  usually  rises 
abruptly,  and  runs  a  very  ir- 
regular course. 

Infrequent. 

Earely  jiresent 

Occasionally  detected. 

Still  more  hurried. 

Common. 

Is  absent. 


Prognosis. — Always  fatal. 

Treatment. — Palliative.  The  diet  should  consist  of  milk, 
eggs,  and  broths.  Stimulants  are  indicated.  High  fever 
should  be  controlled  by  antipyrin  or  by  the  external  applica- 
tion of  cold. 


DIPHTHERIA. 

(Diphtheritis,  Malignant  Sore  Throat,  Cjrnanche  Contagiosa.) 

Definition. — An  acute  contagious  disease  excited  by  the 
Klebs-Lofler  bacillus,  and   characterized  by  moderate  fever, 


DIPHTHERIA.  289 

glandular  enlargements,  great  prostration,  and  a  fibrinous  exu- 
dation which  is  usually  located  in  the  throat. 

Etiology. — Childhood  (between  three  and  six),  defective 
drainage,  and  catarrhal  conditions  of  the  throat  are  predispos- 
ing factors.  The  poison  is  contained  in  the  secretions  of  the 
throat,  and  may  be  transmitted  through  the  atmosphere  or 
through  fomites.  One  attack  does  not  protect  froTn  another, 
but  rather  predisposes. 

The  exciting  cause  is  the  Klebs-Lofler  bacillus,  which  is 
found  only  in  the  membranous  exudation.  The  constitutional 
symptoms  result  from  the  poison  generated  by  the  bacillus. 

Pathology. — The  false  membrane  is  usually  found  on  the 
tonsils,  pillars,  and  pharynx,  but  it  may  extend  to  the  mouth, 
larynx,  or  nose.  The  bacillus  coming  in  contact  with  the 
throat  leads  to  the  death  of  the  superficial  cells,  which  ulti- 
mately undergo  coagulation-necrosis.  The  irritation  causes 
a  migration  of  leucocytes,  and  these  undergo  a  similar  necrosis. 
The  membrane  thus  formed  is  of  a  grayish-white  color,  and  is 
more  or  less  adherent,  so  that  when  torn  off  it  leaves  a  raw 
surface.  Sometimes  the  necrosis  extends  to  the  deeper  tissues 
and  causes  widespread  ulceration  and  even  gangrene.  Micro- 
scopically, the  pseudo-membrane  is  composed  of  fibrin,  leuco- 
cytes, bacteria,  and  the  remains  of  epithelial  cells.  The  lym- 
phatic glands  are  considerably  swollen.  The  spleen  is 
engorged.  The  various  organs  and  the  muscles  reveal  fatty 
and  parenchymatous  degeneration.  Examination  of  the  lungs 
frequently  shows  capillary  bronchitis,  catarrhal  pneumonia, 
and  collapse. 

In  some  cases  the  blood  is  dark  and  fluid,  while  in  others 
firm  clots  are  found  within  the  heart. 

Types. — Diphtheria  may  be  divided  according  to  the  loca- 
tion of  the  exudate  into:  (1)  Faucial ;  (2)  laryngeal;  (3) 
nasal ;  (4)  cutaneous.  According  to  the  severity  of  the  attack 
it  may  be  divided  into :  (1)  Mild ;  (2)  grave ;  (3)  malignant. 

Period  op  Incubation. — Two  to  ten  days. 

Symptoms.     Faucial  Diphtheria. — The  disease  commonly 

begins  with  chills,  moderate  fever,  malaise,  and  sore  throat. 

The  fever,  as  a  rule,  is  not  very  high  (102°-104°)  and  its 

course  is  quite  irregular.     The  pulse  soon  becomes  rapid  and 

19 


290  ACUTE    INFECTIOUS    DISEASES. 

feeble ;  the  bowels  are  constipated ;  the  urine  is  scanty  and 
frequently  albuminous ;  and  the  prostration  and  pallor  are  often 
out  of  all  proportion  to  the  severity  of  the  febrile  symptoms. 

Local  Phenomena. — The  child  complains  of  difficult  swallow- 
ing ;  the  muscles  of  the  neck  feel  stiff;  there  is  tenderness 
under  the  jaw ;  the  lymphatic  glands  are  considerably  swollen; 
and  the  fauces  are  covered  with  a  grayish-white  membrane 
which  when  stripped  off  leaves  a  raw  bleeding  surface,  and  is 
soon  followed  by  a  similar  deposit.  The  membrane  may 
spread  to  the  nose  or  larynx. 

The  course  of  the  disease  is  indefinite,  the  average  duration 
being  from  one  to  two  weeks. 

Laryngeal  Diphtheria. — This  is  usually  secondary  by  exten- 
sion from  the  fauces,  but  it  is  occasionally  primary.  It  is  rec- 
ognized by  hoarseness  or  aphonia,  croupy  cough,  progressive 
dyspnoea,  and  stridulous  breathing.  The  alse  of  the  nose  play  ; 
the  sterno-cleido-mastoids  are  prominent;  the  supra-sternal 
notch  is  deepened ;  and  the  base  of  the  chest  is  retracted. 
Shreds  of  false  membrane  are  sometimes  expectorated  in  the 
violent  fits  of  coughing.  The  febrile  symptoms  are  usually 
slight.  Death  often  results  from  suffocation,  but  recovery  is 
not  impossible  in  the  most  unpromising  cases. 

Nasal  Diphtheria. — -This  is  nearly  always  secondary.  It 
is  recognized  by  grave  constitutional  symptoms — high  fever, 
marked  glandular  involvement,  and  great  prostration ;  by  an 
offensive  discharge  from  the  nose ;  by  epistaxis ;  and  by  ex- 
coriation of  the  lips.  The  false  membrane  may  be  detected 
on  inspection. 

Cutaneous  Diphtheria. — This  form  may  be  primary  or 
secondary.  The  constitutional  symptoms  are  similar  to  those 
of  faucial  diphtheria. 

Complications  and  Sequels. — Capillary  bronchitis, 
catarrhal  pneumonia,  pulmonary  collapse,  myocarditis,  otitis 
media,  nephritis,  and  paralysis. 

Diphtheritic  Paralysis. — This  generally  occurs  during  con- 
valescence and  is  observed  in  about  fifteen  per  cent,  of  all  cases. 
There  is  no  relation  between  the  severitv  of  the  attack  of 
diphtheria  and  the  liability  to  paralysis ;  mild  cases,  which  are 
thought  to  be  simple  pharyngitis,  are  sometimes  followed  by 


DIPHTHERIA.  291 

troublesome  paralysis.  The  pharynx  is  the  most  common 
seat,  and  the  palsy  is  recognized  by  difficult  swallowing  and 
the  regurgitation  of  liquids  through  the  nose.  Next  in  fre- 
quency the  eyes  are  involved,  and  strabismus  or  ptosis  de- 
velops. The  heart  may  be  affected,  and  if  sudden  death  does 
not  result,  the  condition  may  be  manifested  by  a  remarkable 
slowing  of  the  pulse.  In  some  instances  there  is  an  extensive 
involvement  of  the  extremities.  The  paralysis  is  due  to  a 
toxic  neuritis. 

Diagnosis.  Scarlet  Fever. — The  onset  is  more  sudden ; 
the  fever  is  higher  ;  the  pulse  more  rapid  ;  the  tongue  presents 
a  strawberry  appearance ;  a  red  punctiform  rash  appears  on 
the  first  or  second  day  ;  and  if  membrane  appears  on  the 
throat,  it  does  not  contain  the  Klebs-Loffler  bacillus. 

Follicular  Tonsillitis. — In  this  disease  the  yellow  patches 
are  in  the  gland,  not  on  it.  If  false  membrane  is  present,  it 
is  confined  to  the  tonsils  and  does  not  contain  the  Klebs- 
Loffler  bacillus.     Albuminuria  is  very  rarely  present. 

Prognosis. — Always  guarded.  The  mortality  varies  in 
different  epidemics  from  10  to  50  per  cent.  When  the  con- 
stitutional symptoms  are  mild,  and  the  membrane  is  confined 
to  the  fauces  and  shows  little  tendency  to  spread,  the  prognosis 
is  quite  favorable.  The  nasal  and  laryngeal  forms  are  always 
very  grave. 

Treatment.  Prophylaxis. — As  diphtheria  is  prone  to 
attack  unhealthy  mucous  membrane,  naso-pharyngeal  catarrh 
in  children  should  receive  careful  attention.  Large  tonsils 
and  adenoid  growths  should  be  removed.  Those  who  have 
been  exposed  to  the  contagion  should  receive  immunizing 
doses  of  antitoxin.  Patients  with  diphtheria  should  be  kept 
isolated  until  their  throats  are  free  from  virulent  bacilli. 
The  bed-room,  bedding,  clothing,  and  all  utensils  used  by 
the  sick  should  be  thoroughly  disinfected. 

Treatment  of  the  Attack. — Isolation ;  absolute  rest ;  liquid 
diet.  Upon  the  first  evidence  of  heart-failure,  stimulants, 
such  as  alcohol,  strychnine,  strophanthus,  or  caffeine,  should 
be  administered.  Of  the  special  remedies  to  be  exhibited  by 
the  mouth,  iron  and  mercury  have  the  most  advocates.  The 
bichloride  of  mercury  is  well  borne,  and  may  be  given  in 


292  ACUTE    INFECTIOUS    DISEASES. 

doses  of  -^Q  to  ^  of  a  grain  to  a  child  of  four  years.  The 
tincture  of  the  chloride  of  iron  should  be  given,  well  diluted, 
at  short  intervals. 

R     Tinct.  ferri  chloridi,  f^ij  ; 
Glycerini,  f3\j  ; 
Aquse,  q.  s.  ad  f^iv. — M. 
Sig. — Teaspoonful  every  hour  for  a  child  of  four  years. 

It  has  been  fully  demonstrated  that  antitoxin,  or  the  serum 
of  immunized  animals,  is  the  best  therapeutic  agent  in  diph- 
theria. The  investigation  conducted  by  the  American  Ped- 
iatric Society  has  shown  that  the  mortality  under  the  serum 
treatment  in  5794  cases  was  only  12.3  per  cent.,  and  that 
when  the  treatment  was  instituted  during  the  first  three 
days  the  mortality  was  only  7.3  per  cent.  Fifty  per  cent,  of 
the  laryngeal  cases  recovered  without  operation,  and  among 
those  in  which  intubation  was  performed  the  mortality  was 
25.9  per  cent.,  or  less  than  half  as  great  as  has  ever  been 
reported  under  any  other  form  of  treatment.  The  strength 
of  the  serum  is  measured  in  units,  the  latter  being  equal  to 
1  com.  of  "normal  serum,"  which  is  the  blood  serum  of  an 
immunized  animal  so  active  that  -^  of  a  c.cm.  will  antago- 
nize ten  times  the  minimum  of  diphtheria  poison  fatal  to  a 
guinea-pig  weighing  300  grams.  To  a  child  of  two  years 
1000  units  should  be  administered  at  once.  On  the  following 
day,  if  no  improvement  results,  1500  to  2000  units  should  be 
administered,  and  repeated  on  the  third  day  if  necessary. 
Severe  cases,  especially  when  seen  late,  should  receive  the 
maximum  dose  at  the  outset.  The  prophylactic  dose  is  200 
to  500  units.  The  injections  may  be  made  in  the  buttocks, 
flanks,  or  subscapular  region. 

The  atmosphere  of  the  room  should  be  rendered  moist  by 
slacking  lime,  by  evaporating  water  on  the  stove  or  over  a 
spirit-lamp,  or  by  means  of  a  steam  atomizer.  The  addition 
of  turpentine  or  of  oil  of  eucalyptus  to  the  water  is  often  rec- 
ommended. Iodine,  or  an  ointment  of  mercury,  belladonna, 
or  ichthyol,  may  be  applied  to  the  swollen  and  tender  glands. 
The  naso-pharynx  should  be  kept  clean  by  antiseptic  sprays 
or  douches,  and  one  of  the  following  may  be  selected  for  this 


WHOOPING-COUGH.  293 

purpose :  Dobell's  solution,  dilute  listerine,  dilute  peroxide  of 
hydrogen,  chlorine-water,  or  corrosive  sublimate  (1  :  2000), 

Many  solvents  have  been  recommended ;  those  most  com- 
monly employed  are  dilute  lactic  acid,  dilute  hydrochloric  acid 
with  pepsin,  a  solution  of  papayotin,  and  peroxide  of  hydrogen. 
The  last  is  often  useful,  but  it  is  essential  that  it  should  be  fresh. 
When  the  throat  is  not  too  sensitive  it  may  be  employed  undi- 
luted,   Loffler's  solution  is  very  satisfactory.  The  formula  is — 

R    Menthol.,  giiss; 

Toluol.,  q.  s.  ad  f.5x  ; 
■   Solve  et  adde — 

Alcohol,  absolut.,  fSfij ; 
Liquor,  ferri  chloridi,  f^j. — M. 
Sig. — Apply  with  a  cotton  swab. 

In  laryngeal  diphtheria,  when  these  means  fail,  tracheotomy 
or  intubation  must  be  resorted  to. 


WHOOPING-COUGH. 

(Pertussis. ) 

Definition. —  An  infectious  disease,  characterized  by 
catarrh  of  the  respiratory  tract  and  peculiar  paroxysms  of 
cough  ending  in  prolonged  crowing  or  whooping  inspiration. 

Etiology. — The  disease  occurs  both  sporadically  and  epi- 
demically. It  is  most  frequently  met  with  in  children,  but 
unprotected  adults  are  not  exempt.  The  disease  is  unquestion- 
ably contagious,  and  the  virus  seems  to  be  associated  with  the 
sputum.     One  attack  protects  from  others. 

Pathology. — No  characteristic  lesions  are  observed  after 
death.  The  poison  excites  an  inflammation  of  the  respiratory 
mucous  membrane,  and  probably  irritates  the  peripheral  fila- 
ments of  the  pneumogastric  nerve,  and  so  causes  the  parox- 
ysmal cough.  In  fatal  cases,  pulmonary  complications  are 
usually  discovered,  such  as  catarrhal  pneumonia,  pulmonary 
collapse,  and  emphysema. 

Symptoms. — There  are  three  stages :  (1)  The  catarrhal 
stage;  (2)  the  paroxysmal  stage;  and  (3)  the  stage  of  decline. 

Catarrhal  Stage. — The  disease  begins  with  the  symptoms  of 
eoryza,  and  bronchial  catarrh — slight  fever,  sneezing,  running 


294  ACUTE   INFECTIOUS   DISEASES. 

from  the  nose,  dry  cough,  and  rSles.  But  it  does  not  respond 
to  the  ordinary  remedies  for  catarrh,  and  after  lasting  one  or 
two  weeks  passes  into  the  paroxysmal  stage. 

Paroxysmal  Stage. — The  cough  becomes  more  violent  and 
paroxysmal.  During  the  paroxysm  the  face  is  cyanosed,  the 
eyes  are  injected,  and  the  veins  distended.  The  cough  fre- 
quently induces  vomiting,  and,  in  severe  cases,  epistaxis  or 
other  hemorrhages.  The  close  of  the  paroxysm  is  marked  by 
a  long-drawn,  shrill,  whooping  inspiration  due  to  the  spas- 
modic closure  of  the  glottis. 

The  number  of  paroxysms,  or  "  kinks,"  varies  from  ten  or 
twelve  to  forty  or  fifty  in  the  twenty-four  hours.  From  the 
forcible  propulsion  of  the  tongue  against  the  lower  incisors, 
an  ulcer  is  frequently  formed  on  the  frsenum.  The  duration 
of  this  stage  is  three  or  four  weeks. 

Stage  of  Decline. — The  paroxysms  grow  less  frequent  and 
less  violent  and  finally  cease.  Protracted  cases  are  followed 
by  anaemia  and  prostration. 

DuKATiON. — The  entire  duration  of  the  disease  is  from  a 
few  weeks  to  four  months. 

Complications  and  Sequels. —  Catarrhal  pneumonia, 
pulmonary  collapse,  emphysema,  hemorrhage  into  the  conjunc- 
tiva, ear,  or  brain,  and  convulsions.  Grave  cases  are  some- 
times followed  by  nephritis,  chronic  bronchitis,  tuberculosis, 
or  cancrum  oris. 

Diagnosis. — This  can  rarely  be  made  with  certainty  during 
the  catarrhal  stage.  Late?,  the  paroxysmal  cough  ending  in 
vomiting  or  in  whooping  is  absolutely  diagnostic. 

Prognosis. — Guardedly  favorable.  Severe  cases  in  the 
young  and  debilitated  not  infrequently  prove  fatal. 

Treatment. — The  child  should  be  clad  in  flannel  under- 
clothes and  carefully  protected  from  changes  of  temperature. 
During  the  catarrhal  or  febrile  stage  the  patient  should  be  con- 
fined to  bed.  The  diet  should  be  light  and  nutritious.  Coun- 
ter-irritants, like  iodine,  applied  to  the  chest  seem  useful. 
Quinine  is  a  reliable  tonic  and  may  be  employed  throughout 
the  disease.  The  ordinary  expectorant  mixtures  are  valueless. 
Local  applications  to  the  respiratory  mucous  membrane  give 
much  relief.     One  of  the  following  remedies  may  be  inhaled  : 


INFLUENZA,  295 

Creosote  and  chloroform,  dilute  peroxide  of  hydrogen,  or  a 
solution  of  menthol. 

]^  Menthol,  gr.  xx  ; 

Petrolat.  liquid.,  f.5J. — M. 
Sig. — Spray  the  naso-pharynx  and  inhale  several  times  a  day. 

In  very  young  children  a  solution  of  menthol  may  be  in- 
haled from  a  cloth  held  under  the  chin.  When  paroxysms  are 
violent  the  inhalation  of  a  few  drops  of  nitrite  of  amyl  is  de- 
sirable. 

The  following  antispasmodic  remedies  appear  to  lessen  the 
severity  and  the  frequency  of  the  paroxysms:  belladonna,  anti- 
pyrin,  asafoetida,  and  bromoform  (gtt.  i-iv),  potassium  bromide. 

^   Sodii  bromidi,  giss  ; 
Tinct.  belladonnse,  fgj  ; 
Glycerini,  fgss ; 
Aquae,  q.  s.  ad  f^ij. — M, 
Sig. — A  teaspoonful  every  three  or  four  hours. 

Or— 

^  Antipyrin,  gr.  xl-lx  ; 
Syr.  tolutan.,  f^J  ; 
Aquse  q.  s.  ad  f^ij. — M. 
Sig. — A  teaspoonful  every  two  or  three  hours. 

INFLUENZA. 

(La  Grippe,  Catarrhal  Fever,  Epidemic  Catarrh.) 

Definition. — An  acute  infectious  disease,  characterized  by 
fever,  extreme  prostration,  pain  in  the  head  and  back,  and 
generally  by  catarrh  of  the  respiratory  or  gastro-intestinal 
tract. 

Etiology. — The  disease  occurs  in  epidemics  which  usually 
have  their  origin  in  Russia,  whence  they  spread  with  wonder- 
ful rapidity  over  both  continents.  The  exciting  cause  is  with- 
out doubt  a  small  bacillus  found  in  the  sputum,  and  first  dis- 
covered by  Pfeiffer  in  1892.  When  prevalent,  no  age  and 
neither  sex  is  exempt.  One  attack  does  not  confer  immunity 
from  others. 

Pathology. — Influenza  does  not  often  kill  save  by  its 
complications.     The  latter  are  most  frequently  associated  with 


296  ACUTE    INFECTIOUS   DISEASES. 

the  respiratory  tract,  and  consist  of  capillary  bronchitis,  catar- 
rhal pneumonia,  and  croupous  pneumonia. 

Symptoms. — The  disease  begins  abruptly  with  lassitude, 
malaise,  chilliness,  severe  pain  in  the  head  and  back,  fever 
ranging  between  101°  and  103°,  and  extreme  prostration, 
vv'hich  is  out  of  proportion  to  the  fever  and  any  existing  local 
inflammation.  The  catarrhal  symptoms  are  injection  of  the 
eyes,  sneezing,  hoarseness,  and  hard  paroxysmal  cough.  In 
simple  cases  the  temperature  falls  in  two  or  three  days  by 
crisis,  but  complications  not  infrequently  prolong  the  case  for 
several  weeks. 

In  some  cases  the  catarrh  of  the  respiratory  tract  is  the 
chief  feature  ;  in  others  the  gastro-intestinal  tract  is  attacked, 
and  the  symptoms  resemble  cholera  morbus  ;  in  a  third  group 
neuralgic  pains  in  the  head,  back,  and  limbs  are  the  most 
striking  phenomena. 

Co:*rPLiCATioxs. — Catarrhal  pneumonia,  croupous  pneu- 
monia, pleurisy,  nephritis,  neuritis,  meningitis,  and  insanity. 

Diagnosis.  "  Acute  Bronchitis. — The  fever  is  not  so  high  ; 
there  is  little  or  no  prostration  ;  and  the  pains  in  the  head  and 
back  are  not  nearly  so  marked  as  in  influenza. 

Typhoid  Fever.^-The  gradual  onset,  typical  temperature 
curve,  epistaxis,  diarrhoea,  and  rash  will  indicate  typhoid 
fever. 

Prognosis. — Uncomplicated  cases  nearly  always  recover. 
In  the  very  old,  and  in  those  debilitated  by  chronic  disease, 
influenza  not  infrequently  proves  fatal. 

Treatment. — Absolute  rest  in  bed  and  a  liquid  diet.  As 
there  is  no  specific,  the  treatment  is  symptomatic.  Quinine  is  a 
useful  stimulant,  and  when  the  stomach  is  irritable  it  may  be 
given  by  the  rectum. 

The  Fains.  — Hot-waiev  bags  to  the  head  and  spine ; 
morphine,  or  combinations  of  autipyrin  or  phenacetin  with 
salol  or  salicin,  thus  : — 

R     Salol,  3ss ; 

Phenacetin,  5j- — M. 
rt.  in  chart.  No.  xii. 
Sig.— One  every  two  hours. 


MUMPS.  297 

Or— 

^  Quininse  salicylat.,  gr.  xl ; 
Phenacetiu^  3i. — M. 
In  20  capsules. 
■  Sig. — One  every  two  hours. 

Or— 

R   Salicini,  aa  3ij  ; 
Phenacetin,  5iss ; 
Olei  gaulther.,  gtt.  v; 
Syr.  acacise,  f^iij. — M. 
Sig. — Teaspoonful  every  hour  or  two. 

Heart-failure  should  be  combated  by  alcohol  and  strychnine. 
Bronchial  catarrh  will  require  the  remedies  indicated  in  simple 
bronchitis.  Sleep  may  be  induced  by  opium,  sulphonal,  or 
bromide  of  potassium. 

MUMPS. 

(Epidemic  Parotitis.) 

Definition. — An  acute  contagious  disease,  characterized 
by  inflammation  of  the  parotid  and  other  salivary  glands. 

Etiology. — The  disease  occurs  sporadically  and  epidemi- 
cally. It  is  most  frequently  observed  in  young  children^  but 
unprotected  adults  are  not  exempt.  Males  are  more  suscep- 
tible than  females.  The  disease  is  highly  contagious,  and  the 
virus  is  probably  contained  in  the  saliva,  but  it  has  not  been 
isolated.     One  attack  confers  immunity  from  others. 

Pathology. — As  the  disease  is  so  seldom  fatal  very  little 
opportunity  is  afforded  for  studying  its  intimate  pathology. 
The  parotid  glands  are  the  seat  of  an  inflammatory  infiltration, 
but  suppuration  does  not  occur.  The  inflammation  shows  a 
marked  tendency  to  leave  the  parotids  and  to  involve  the  testes 
in  the  male,  or  more  rarely  the  mammse  or  ovaries  in  the  female. 

Period  of  Incubation. — One  to  two  weeks. 

Symptoms. — The  disease  is  ushered  in  with  chilliness,  mal- 
aise, and  moderate  fever  (101°-104°),  followed  by  swelling 
of  one  parotid  gland.  The  swelling  is  observed  below  and 
in  front  of  the  ear,  is  pyriform  in  shape,  and  has  a  doughy 
feel.  The  surrounding  tissues  are  cedematous,  the  submaxil- 
lary glands  are  likewise  swollen,  and  the  features  may  be  dis- 


298  ACUTE    INFECTIOUS   DISEASES. 

torted  beyond  recognition.  The  movements  of  the  jaw  are 
restricted  and  painful.  The  saliva  may  be  increased  or  di- 
minished. In  many  cases  the  other  parotid  becomes  similarly 
affected. 

Often  in  the  course  of  the  disease  the  inflammation  suddenly 
subsides  in  the  parotid  gland  and  reappears  in  the  testicle  in 
the  male,  or  in  the  ovary  or  mamma  in  the  female. 

The  duration  of  the  disease  is  usually  five  or  six  days. 

Complications. — Hyperpyrexia,  metastasis  to  the  testicle 
or  ovary,  and  meningitis.  Atrophy  of  the  testicle  rarely 
follows. 

Prognosis.- — Favorable. 

Treatment. — Rest  in  bed.  Mild  febrifuges  may  be  given 
internally.  Locally,  lead-water  and  laudanum,  or  some  rube- 
facient liniment  like  the  following,  may  be  employed  : — 

R  Tinct.  iodi, 

Tiuct.  aconit.  rad., 
Tinct.  opii,  aa  f^ij  ; 

Liniment,  chloroform.,  q.  s.  ad  f5iij. — M. 
Sig. — Apply  externally  and  cover  with  cotton- wool. 

The  swollen  testicle  should  be  elevated  and  covered  with 
lint  saturated  with  lead-water  and  laudanum.  If  the  swelling 
persists,  an  ointment  of  mercury,  belladonna,  and  ichthyol  will 
be  found  useful. 

CHOLERA. 

(Asiatic  Cholera,  Epidemic  Cholera,  Malignant  Cholera.) 

Definition. — An  acute  infectious  disease,  generally  epi- 
demic, excited  by  Koch's  comma-bacillus,  and  characterized 
by  vomiting  and  purging  of  a  serous  material,  painful  cramps, 
and  collapse. 

Etiology. — Cholera  has  its  origin  in  India,  and  is  carried 
thence  to  other  parts  of  the  world.  The  exciting  cause  is  the 
comma-bacillus  of  Koch  ;  this  usually  has  the  form  of  a 
slightly-(turved  rod,  but  it  is  occasionally  S-shaped.  The  rice- 
water  evacuations  only  contain  the  bacilli,  which,  under  favor- 
able conditions,  continue  to  grow  outside  of  the  body,  and 
by  gaining  entrance  into  the   healthy  system   propagate  the 


CHOLERA.  299 

disease.  The  disease  always  spreads  along  the  lines  of  traffic, 
hence  epidemics  nearly  always  begin  at 'the  sea-coast  and  ex- 
tend inland.  Cholera  is  slightly,  if  at  all,  contagious  ;  like 
typhoid  fever,  the  poison  is  not  carried  through  air,  but  chiefly 
through  drinking-water.  Laundresses  and  nurses,  from  their 
contact  with  the  evacuations,  readily  acquire  the  disease.  Epi- 
demics are  more  frequent  in  summer  than  in  winter.  No  age 
is  exempt,  but  the  old  are  more  susceptible  than  the  young. 
The  intemperate,  the  debilitated,  and  those  suffering  with  gas- 
tro-intestinal  catarrh  are  especially  predisposed. 

Pathology. — The  body  is  shrivelled ;  movements  of  the 
corpse  are  sometimes  observed  ;  rigor  mortis  is  marked  and 
prolonged.  The  tissues  are  dry,  and  the  large  veins  and  right 
side  of  the  heart  contain  thick,  dark  blood.  The  serous  cavi- 
ties are  empty  and  their  surfaces  sticky.  The  intestines  con- 
tain more  or  less  rice-water  fluid,  from  which  cultures  of 
bacilli  can  be  made. 

The  mucous  membrane  has  a  pinkish  color  and  is  often  the 
seat  of  ecchymoses ;  the  solitary  and  Peyer's  glands  are  swol- 
len. Frequently  extensive  desquamation  of  the  epithelial 
lining  is  observed,  but  this  is  usually  regarded  as  a  post-mor- 
tem change.  The  kidneys  reveal  evidences  of  parenchymatous 
inflammation  ;  the  liver  is  the  seat  of  fatty  degeneration. 

As  the  lesions  are  not  sufficient  to  explain  the  clinical  phe- 
nomena, it  has  been  suggested  by  Koch  that  the  bacilli  create 
a  poison  the  absorption  of  which  causes  the  grave  symptoms. 

Period  of  Incubation. — A  few  hours  to  several  days. 

Symptoms. — The  severity  of  the  symptoms  varies  consider- 
ably. In  well-marked,  but  favorable,  cases  there  are  three 
stages  :  (1)  Invasion  ;  (2)  algid  or  collapse  ;  (3)  reaction. 

^tage  of  Invasion. — The  disease  usually  begins  with  malaise, 
headache,  diarrhoea,  rumbling  noises  in  the  intestines,  and 
colic.  Frequently  these  symptoms  continue  a  few  days  and 
then  subside  ;  such  cases  are  termed  cholerine,  and  are  as  infec- 
tious as  the  fully-developed  disease. 

Stage  of  Collapse. — The  diarrhoea  grows  more  marked  ;  the 
evacuations  become  copious,  lose  their  feculent  character,  assume 
a  rice-water  appearance,  and  are  discharged  forcibly  but  with- 
out pain.     Vomiting  soon  develops,  and  the  ejected  materia] 


300  ACUTE    INFECTIOUS    DISEASES. 

resembles  that  passed  by  the  bowel.  Thirst  is  unquenchable. 
Severe  cramps  seize  the  muscles  of  the  calves  of  the  legs,  thighs, 
arms,  and  abdomen.  The  surface  is  cold  and  covered  with  a 
clammy  sweat ;  the  breath  is  cool  ;  the  temperature  in  the 
axilla  ranges  from  95°  to  85°,  while  in  the  rectum  it  may  rise  to 
103°  or  more.  The  voice  is  husky  and  finally  reduced  to  a 
whisper ;  the  respirations  are  quickened  ;  the  pulse  becomes 
more  and  more  feeble  ;  the  body  is  livid  and  shrivelled  ;  the 
hands  resemble  those  of  a  washerwoman  ;  the  features  are 
pinched  and  sometimes  distorted  ;  the  eyes  are  frightfully 
sunken.  The  urine  is  more  or  less  suppressed,  and  the  little 
that  is  passed  generally  contains  albumin  and  a  trace  of  sugar. 
Consciousness  is  usually  retained  until  near  the  end,  when  coma 
sets  in. 

The  duration  of  this  stage  is  from  a  few  hours  to  two  days. 

Stage  of  Reaction. — Sometimes,  even  when  death  seems  im- 
minent, the  surface-temperature  begins  to  rise  ;  the  urine  in- 
creases ;  the  pulse  strengthens ;  the  vomiting  ceases ;  the 
evacuations  from  the  bowels  become  less  frequent  and  begin 
to  assume  a  feculent  character,  and  convalescence  is  established. 

Occasionally,  instead  of  convalescence,  symptoms  of  a  typhoid 
type  develop,  such  as  moderate  fever,  a  brown,  fissured  tongue, 
subsultus,  muttering  delirium,  and  coma.  This  condition, 
which  is  generally  fatal,  has  been  regarded  as  ursemic. 

Cholera  Sicca. — In  very  violent  cases  collapse  and  death 
may  follow  without  there  having  been  any  evacuation.  After 
death  the  intestines  contain  rice-water  fluid,  which  was  not 
discharged  during  life  probably  on  account  of  paralysis  of  the 
muscular  coat  of  the  bowel. 

Complications  and  SEQUELiE. — Nephritis,  pneumonia, 
pleurisy,  parotitis,  ulceration  of  the  cornea,  diphtheritic  in- 
flammation of  the  throat  and  fauces,  abscesses,  and  local  gan- 
grene. 

Diagnosis.  Cholera  Morbus. — This  is  always  sporadic ; 
the  discharges  are  bilious  in  character ;  a  history  of  dietetic 
errors  and  of  exposure  can  usually  be  obtained ;  and  the  comma- 
bacilli  are  not  detected  in  the  discharges. 

Prognosis. — Generally  unfavorable.  The  mortality  aver- 
ages about  50  per  cent.     In  the  old,  young,  debilitated,  and 


CHOLERA,  301 

intemperate  it  is  very  fatal.     In  individual  cases,  early  col- 
lapse and  a  low  surface  temperature  are  unfavorable  conditions. 

Teeatment.  Prevention. — This  includes  the  isolation  of 
the  sick  ;  absolute  cleanliness  ;  the  disinfection  of  excreta  and 
soiled  bed-clothes ;  the  thorough  boiling  of  all  water  that  is  to 
be  used  for  drinking  purposes ;  the  use  of  a  bland,  unirritating 
diet ;  the  avoidance  of  overwork,  exposure,  and  undue  excite- 
ment ;  and  the  prompt  treatment  of  any  gastro-intestinal  dis- 
turbance that  may  arise. 

The  Attach. — The  violent  vomiting  and  purging  and  the 
cramps  call  for  morphine ;  this  is  best  administered  hypoder- 
mically.  There  are  no  specifics.  A  remedy  frequently  recom- 
mended by  competent  observers  is  sulphuric  acid,  which  may  be 
given  with  laudanum  or  chlorodyne.  Thirst  is  best  assuaged 
by  cracked  ice  ad  libitum  and  acidulated  drinks.  For  the 
vomiting  a  mustard  poultice  may  be  applied  to  the  epigastrium, 
and  iced  champagne,  carbolic  acid,  creosote,  or  dilute  hydro- 
cyanic acid  may  be  given  internally.  For  the  cramps  the 
application  of  hot-water  bags,  warm  fomentations,  or  the  rub- 
bing in  of  warm  oil  may  be  useful ;  when  they  are  very  severe 
a  few  whifFs  of  chloroform  may  be  employed.  When  the  pulse 
weakens,  stimulants  like  alcohol,  ether,  and  ammonia  should 
be  given  freely. 

Copious  warm-water  enemata  containing  tannic  acid  (1  per 
cent.)  and  laudanum  are  highly  recommended  for  the  purging. 

The  low  temperature  must  be  combated  by  the  use  of  hot 
blankets,  or,  better  still,  by  immersion  in  warm  baths  (98°  to 
104°).  In  collapse,  subcutaneous  or  intravenous  injections  of 
saline  solutions  have  been  highly  recommended.  The  follow- 
ing solution,  which  is  well  spoken  of  by  Fagge,  may  be 
injected  directly  into  the  veins,  or  may  be  allowed  to  flow 
through  a  rubber  tube  attached  to  an  aspirating  canula,  and 
to  enter  the  subcutaneous  tissue  by  its  own  pressure  : — 

^   Sodii  phos.,  gr.  iij  ; 
Sodii  chlorid.,  3j  ; 
Potass,  chlorid.,  gr.  vj  ; 
Sodii  carb. ,  gr.  xx  ; 
Alcohol,  f^ij; 
Aquse  destil.,  f^xx.— M. 


302  ACUTE   INFECTIOUS    DISEASES. 

The  fluid  should  be  warm,  and  the  injection  should  be  con- 
tinued until  the  pulse  strengthens ;  as  much  as  eighty  ounces 
may  be  introduced  at  one  time. 

The  diet  should  consist  of  the  following  :  Light  broths,  milk 
with  carbonated  water,  koumiss,  wine-whey^  thin  gruels,  and 
frozen  blocks  of  beef-tea. 

TETANUS. 

(Lockjaw.) 

Definition. — An  acute  infectious  disease  excited  by  a 
special  bacillus,  and  characterized  by  painful  tonic  spasms  of 
the  voluntary  muscles. 

Etiology. — In  the  tropics,  especially  in  the  colored  race, 
the  disease  often  arises  idiopathically.  In  temperate  climates 
the  poison  nearly  always  gains  entrance  through  a  wound. 
Lacerated  and  punctured  wounds,  frost-bites,  and  burns  are 
especially  liable  to  become  infected.  Exposure  to  cold  and 
wet  after  traumatism  seems  to  predispose.  Since  the  intro- 
duction of  antiseptic  surgery  tetanus  is  less  common  than 
formerly. 

The  exciting  cause  is  a  special  microorganism — the  tetanus 
bacillus. 

Pathology. — Congestion  of  the  spinal  cord  and  of  the 
nerves  leading  to  the  wound. 

Symptoms. — The  disease  begins  with  a  feeling  of  rigidity 
in  the  muscles  of  the  neck  and  lower  jaw ;  by  degrees  the 
muscles  of  the  back,  abdomen,  aud  lower  extremities  are 
similarly  involved.  The  brow  is  wrinkled,  the  corners  of  the 
mouth  are  drawn  upwards  (^risus  sardonicus),  the  jaws  are 
tightly  closed  (trismus),  and  the  body  becomes  arched,  the 
patient  resting  on  his  head  and  heels  {opisthotonos).  There  is 
extreme  hypersesthesia,  so  that  the  slightest  touch  causes  a 
violent  exacerbation  of  the  spasm,  which  is  attended  by  ex- 
cruciating pain.  If  the  respiratory  muscles  are  involved,  there 
is  intense  dyspnoea.  The  temperature  usually  remains  normal 
until  just  before  death,  when  it  may  rise  to  107°  or  more. 
The  mind  is  clear  to  the  end.  The  duration  is  from  a  few 
days  to  several  weeks. 


DENGUE.  303 

Diagnosis.  Strychnia-poisoning. — The  history  of  the  case, 
the  complete  relaxation  between  the  spasms,  and  the  late  in- 
volvement of  the  jaw  will  indicate  strychnia-poisoning. 

Tetany. — The  history,  the  paroxysmal  character  of  the 
spasms,  the  involvement  of  the  hands,  and  the  escape  of  the 
trunk  and  jaw  will  serve  to  distinguish  tetany  from  tetanus. 

Peognosis. — Unfavorable.  Slight  involvement  of  the 
muscles  of  the  trunk,  absence  of  fever,  and  a  slow  course  are 
favorable  features. 

Treatment. — The  wound  should  be  rendered  aseptic. 
Morphine  is  indicated  for  the  relief  of  the  pain.  Bromide  of 
potassium  (3j  every  two  hours)  and  chloral  should  be  used  to 
control  the  convulsions.  When  asphyxia  is  threatened  by  the 
violence  of  the  spasm,  inhalations  of  chloroform  should  be 
employed.  When  the  patient  is  unable  to  swallow,  he  must 
be  fed  through  the  nose  or    by  the  rectum. 

Antitoxins  derived  from  the  blood  of  animals  which  have 
been  rendered  immune  will  doubtless  prove  to  be  a  valuable 
addition  to  the  therapy  of  this  dread  disease. 

DENGUE. 

(Break-bone  Fever,  Dandy  Fever.) 

Definition. — An  acute  infectious  disease,  characterized  by- 
pains  in  the  muscles  and  joints,  a  variable  rash,  and  a  febrile 
course  of  two  paroxysms. 

Etiology. — Dengue  is  confined  almost  entirely  to  hot  cli- 
mates. Although  it  occurs  in  epidemics,  its  contagiousness  is 
still  a  matter  of  dispute. 

Period  of  Incubation. — Three  to  five  days. 

Symptoms. — The  invasion  is  usually  sudden  and  is  attended 
with  lassitude,  chilliness,  headache,  intense  pain  in  the  muscles 
and  joints,  and  high  fever.  The  latter  rises  rapidly  and  often 
reaches  a  maximum  of  104°-105°  in  a  few  hours.  The  pulse 
is  rapid  and  full ;  the  respirations  are  accelerated;  the  mind  is 
often  delirious  ;  the  urine  is  scanty  ;  the  joints  are  swollen  and 
stiff.  In  two  or  three  days  the  temperature  falls,  and  an 
afebrile  period  follows  in  which  the  patient  is  free  from  pain, 
but  is  profoundly  prostrated.     During  the  remission  a  roseo- 


304  ACUTE    INFECTIOUS   DISEASES. 

lar  or  a  diffuse  erythematous  rash  generally  appears ;  this  lasts 
two  or  three  days  and  is  followed  by  slight  desquamation. 
Shortly  after  the  subsidence  of  the  rash,  the  fever  and  pains 
again  return,  and  persist  for  two  or  three  days  when  conva- 
lescence begins. 

Diagnosis. — Acute  Rheumatism.  The  prevalence  of  an 
epidemic,  and  the  distinct  remission  will  usually  render  the 
diagnosis  apparent. 

Prognosis. — Favorable. 

Treatment. — There  is  no  specific  remedy.  High  fever 
should  be  controlled  by  the  external  application  of  cold  or  by 
the  use  of  antipyrin.  Morphiue,  salol,  antipyrin,  or  phenacetin 
may  be  employed  to  relieve  pain.  Prostration  must  be  com- 
bated by  stimulants,  like  alcohol,  quinine,  and  strychnine. 


HYDROPHOBIA. 

(Rabies.) 

Definition. — A  disease  of  dogs  and  kindred  animals,  com- 
municated to  man  by  direct  inoculation,  and  characterized  by 
slight  fever,  painful  spasm  of  the  muscles  of  the  throat,  deli- 
rium, paralysis,  and  coma. 

Etiology. — Rabies  invariably  results  from  the  bite  of  a 
rabid  animal,  generally  a  dog.  In  the  animal  the  disease  is 
characterized  by  depression  of  spirits,  loss  of  appetite,  followed 
by  excitement,  aimless  roving,  a  morbid  desire  to  bite,  and 
finally  by  paralysis  and  death  from  exhaustion.  The  poison  is 
contained  in  the  saliva  and  blood.  Pasteur  has  induced  the 
disease  by  direct  inoculation,  and  has  found  that  the  virus  is 
attenuated  by  passing  several  times  through  the  monkey. 
Bites  on  the  face  and  on  exposed  parts  are  particularly  liable 
to  be  followed  by  infection. 

Pathology. — Intense  congestion  of  the  spinal  cord  and  of 
the  respiratory  mucous  membrane. 

Period  of  Incubation. — Six  weeks  to  six  months.  ^- 

Symptoms.  First  Stage. — Depression  of  spirits,  restless- 
ness, slight  difficulty  in  swallowing,  and  pain  in  the  wound  or 
cicatrix.     In  a  few  days  the  stage  of  excitement  begins. 


HYDROPHOBIA.  305 

Second  Stage. — Clonic  convulsions,  involving  especially  the 
muscles  of  the  throat,  occurring  spontaneously  or  excited  by 
drinking  or  by  the  sight  of  water ;  hypersesthesia,  delirium, 
modei'ate  fever,  and  salivation.  This  stage  lasts  a  few  days, 
and  is  followed  by  paralysis. 

Third  Stage. — The  pulse  weakens  ;  the  convulsions  cease  ; 
the  patient  lies  motionless ;  the  mind  becomes  clouded  ;  and 
death  results  in  twelve  or  twenty-four  hours  from  exhaustion. 

Diagnosis. — Hysteria  in  persons  who  have  been  bitten 
may  simulate  hydrophobia.  Such  persons  often  bark,  try  to 
bite,  and  manifest  other  symptoms  which  are  not  noted  in  hy- 
drophobia. 

Prognosis. — Invariably  fatal. 

Treatment.  Prophylaxis.  —  Suspicious  bites  should  be 
thoroughly  disinfected  and  cauterized  by  the  hot  iron  or  caus- 
tic potash,  after  which  the  patient  should  be  sent  to  an  institute 
where  inoculation  may  be  practised  after  the  method  of 
Pasteur. 

The  Attack. — Palliative.  For  the  convulsive  seizures  mor- 
phine may  be  employed  hypodermically,  and  chloroform  by  in- 
halation. The  strength  may  be  sustained  bv  rectal  alimentation. 
20  '  . 


I 


CONSTITUTIONAL  DISEASES. 


RHEUMATIC  FEVER. 

(Acute  Articular  Rheumatism,   Inflammatory  Rheumatism.) 

Definition. — An  acute  general  disease,  characterized  by 
irregular  fever,  acid  sweats,  inflammation  of  the  joints,  and  a 
marked  tendency  to  involve  the  heart.     .^■■^^^■^^^'>^  '•^■■'■^j-i  (f"-'"'''^" 

Etiology. — Heredity,  temperate  zone,  occupations  which 
necessitate  exposure  to  cold  and  wet,  early  life  (15-40),  and 
one  attack  are  predisposing  factors.  The  disease  is  usually 
precipitated  by  sudden  chilling  of  the  body. 

The  exciting  cause  is  still  unknown.  Some  regard  it  as  a 
neurosis ;  others  believe  it  to  be  infectious,  and  classify  it  with 
pneumonia,  erysipelas,  and  similar  diseases ;  while  still  others 
attribute  it  to  deranged  metabolism.  According  to  the  last 
theory,  the  nitrogenous  products,  instead  of  being  converted  into 
urea,  are  transformed  into  lactic  acid,  uric  acid,  and  other  allied 
substances,  and  these  deleterious  agents  are  responsible  for  the 
symptoms. 

Pathology. — The  ligaments  and  the  synovial  membrane 
and  its  fringes  are  congested  and  swollen.  The  synovial  sac  is 
filled  with  a  turbid  fluid.  The  cartilag-es  are  rouarhened  and 
occasionally  ulcerated.  Generally  the  process  ends  in  resolu- 
tion ;  sometimes  the  surroundiug  tissues  become  infiltrated 
with  inflammatory  lymph,  and  false  anchylosis  results  ;  rarely, 
suppuration  of  the  joint  follows.  Sometimes  small,  subcuta- 
neous, fibrous  nodules  are  found  near  the  joints  and  large  ten- 
dons. The  blood  shows  an  excess  of  fibrin  and  a  considerable 
diminution  of  the  red  corpuscles.  Fibrinous  clots  are  often 
found  in  the  heart  and  great  bloodvessels. 

Secondary  inflammations  are  frequently  discovered,  such  as 
endocarditis,  pericarditis,  pleurisy,  or  pneumonia. 
(306) 


RHEUMATIC   FEVER.  307 

SYiiPTOMS. — The  symptoms  vary  much   in  their  severity. 
The  disease  usually  begins  abruptly,  or  more  rarely  follows  such 
'  prodromes   as  malaise,  chilliness,  and  sore  throat.     The  large 
_^JloiiitSj_ especially  the   symmetrical   ones,  are  usually  aifected  ; 
-they  are  slightly  reddened,  swollen,  exquisitely  painful,  and 
',  tender  to  the  touch.     The  inflammation  shows  a  marked  ten- 
^  dency  not  only  to  spread  from  joint  to  joint,  but  to  disappear_ 
.0  abjnipth^  in  one  while  it  attacks  another.     The  joinfs  most 
commonly  involved    are  the  knees,  elbows,  ankles,  and  wrist ; 
but  no  joint  is  exempt.     In  severe  cases  the  muscles  are  pain- 
ful, tender,  and  sometimes  rigid.     The  fever  rises  rapidly  to  a 
moderate  height  (102°-103°),  and  is  indefinite  in  its  duration 
and  extremely  irregular  in  its  course.     Perspiration  is  often 
copious,  has  a  peculiar  sour  smell  and  an  .acid  reaction.     The 
urine  is  scanty,  high-colored,  aud  on  standing  throws  down  an 
abundant    sediment  of  urates  and   uric  acid.    The  tongue  is 
heavily  coated  ;  the  appetite  is  lost ;  and  the  bowels  are  con- 
stipated.    The  face  is   at   first    flushed,    but   as   the   disease 
advances  it  becomes  decidedly  pale  from  aneemia. 

The  duration  is  indefinite,  varying  from  a  few  days  to 
several  weeks. 

Complications. — Endocarditis  (in  40  per  cent,  of  all  cases); 
pleuris}^;  pericarditis;  pneumonia;  hyperpyrexia  (106°-109°), 
which  is  often  associated  Mith  maniacal  dehrium;  chorea;  iritis; 
meningitis;  and  certain  cutaneous  phenomena,  such  as  urticaria, 
purpura,  erythema  nodosum,  and  subcutaneous  fibrous  nodules. 

Diagnosis.  Septic  Arthritis. — This  may  be  recognized  by 
its  association  with  some  other  septic  process  and  by  the  special 
tendency  of  the  inflammation  to  end  in  suppuration,  which  is  a 
very  rare  termination  of  rheumatic  fever, 

Gonorrhceal  Rheumatisra. — This  may  be  recognized  by  the 
history,  by  its  obstinate  character,  and  by  its  tendency  to  in- 
volve, not  only  large  joints,  but  certain  small  joints  which  are 
rarely  affected  in  rheumatic  fever,  like  the  sterno-clavicular, 
temporo-maxillary,  and  sacro-iliac. 

Rheumatoid  Arthritis. — This  begins  in  the  small  joints, 
attacks  one  after  another,  leads  to  permanent  deformity,  is  not 
associated  with  fever  and  s\veatS;  and  shows  no  tendency  to 
involve  the  heart. 


308  CONSTITUTIONAL  DISEASES. 

Gout. — This  occurs  later  in  life,  usually  involves  the  great 
toe,  and  lacks  high  fever,  acid  sweats,  and  the  tendency  to 
heart  complications. 

Prognosis. — Guarded.  Most  cases  end  in  recovery ;  sonie 
in  chronic  rheumatism ;  a  very  small  number  die  of 
exhaustion,  or  some  complication,  such  as  hyperpyrexia.  It 
is  very  prone  to  relapse  and  to  recur.  The  most  frequent 
complication  is  endocarditis  ;  this  may  never  give  rise  to 
trouble,  but  frequently  it  leads  to  slow  thickening  or  retrac- 
tion of  the  valves  and  to  all  the  phenomena  of  chronic  heart 
disease. 

Treatment. — Absolute  rest  in  a  room  well-ventilated  but 
free  from  draft ;  the  patient  should  lie  between  blankets. 
The  diet  should  consist  mainly  of  milk  and  light  broths  ;  meat 
should  be  interdicted.  The  free  use  of  lemonade  or  mineral 
waters  should  be  encouraged.  Opium,  phenacetin,  or  antipy- 
rin  may  be  required  to  relieve  the  pain. 

Two  remedies  have  considerable  power  in  controlling  the 
disease  :  salicyl  compounds,  and  alkalies,  like  the  salts  of  potas- 
sium ;  these  remedies  may  be  given  separately  or  in  combina- 
tion. The  salicylates  relieve  the  pain,  but  do  not  prevent  re- 
lapses or  cardiac  complications  ;  the  alkalies  apparently  lessen 
the  tendency  to  endocarditis. 

Salicylic  acid  (gr.  x  in  capsules)  or  salicylate  of  sodium  (gr. 
x-xx)  may  be  given  every  two  hours.  Large  doses  may  excite 
nausea  and  ringing  in  the  ears. 

^   Sodii  salicylat.,  ^ij  ; 

Tinct.  cardamom,  comp.,  f^iv; 
Glycerin.,  f^ij  ; 
Aquse  q.  s.  ad  fgiv.— M. 
Sig. — A  tablespoonful  every  two  hours. 

The  oil  of  gaultheria  (n^x  every  two  hours)  is  another  sali- 
cyl compound  of  decided  value.  If  alkalies  are  employed, 
half  a  drachm  of  bicarbonate  of  potassium  may  be  administered 
every  two  hours  until  the  urine  becomes  distinctly  alkaline. 
It  is  a  good  plan  to  combine  alkalies  with  salicylates,  thus 


EHEUMATIC  FEVEE.  309 

^  Sodii  salicylat.,  gij  ; 
Potass,  bicarb.,  giij  ; 
Glycerini, 

Tinct.  cardamom,  comp.,  aa  f§ss  ; 
Aqu£e  q.  s.  ad  f^v.— M. 
Sig. — A  tablespoonful  every  two  hours. 

When  there  is  much  ansemia  Basham's  mixture  (5j-Iss) 
may  be  given  with  the  salicylate,  or  the  following  combina- 
tion may  be  employed  : — 

1^  Acid,  salicylic,  ^ss  ; 
Ferri  pyrophosphat.,  ^j  ; 
Sodii  phosphatis,  gx ; 
Aquse,  f^vj.— M.     (Peabodt.) 
Sig. — Tablespoonful  every  two  hours  until  relieved. 

Local  Treatment. — The  joints  may  be  painted  with  iodine 
and  wrapped  in  cotton-wool.  In  severe  cases  small  blisters 
are  of  great  utility.  Chloroform  liniment,  aconite  liniment, 
lead-water  and  laudanum  are  also  efficient  remedies.  The 
salicyl  preparations,  when  applied  locally,  often  relieve  the 
pain  better  than  any  other  remedy.  The  following  mixture 
may  be  employed  : — 

^  ^ther., 
Alcohol., 

01.  gaultherise,  aa  §j  ; 
Lin.  saponis  q.  s.  ad  Oj. — M. 
Sig. — Apply  locally. 

Or— 

^  01.  gaultherise, 

01.  olivse, 

Lin.  saponis, 

Tinct.  aconit., 

Tinct.  opii,  aa  fjiss. — M. 
Ft.  liniment. 
Sig. — Apply  locally. 

Sometimes  ichthyol  proves  serviceable. 

^   Ichthyol,  3ij  ; 

Ext.  belladonnse,  3j  ; 
Yaselin.,  ^ij. — M. 
Sig. — Apply  locally. 

Hypeiyyrexia.  —  This  should  be  treated  promptly  by  the 
cold  pack  or  the  cold  bath. 


310  CONSTITUTIONAL.  DISEASES. 

Endocarditis. — This  usually  causes  no  subjective  disturbance 
and  the  general  treatment  need  not  be  modified.  When  the 
pulse  is  rapid  and  irregular,  and  the  patient  complains  of 
precordial  distress,  a  blister  may  be  applied  and  digitalis  may 
be  given  internally.  Absorbents  like  the  iodide  of  potassium 
are  useless.  Convalescence  should  be  protracted  so  as  to  allow 
time  for  perfect  compensation. 

Convalescence. — Such  tonics  as  iron,  quinine,  and  strychnine 
are  useful  during  this  period. 

CHRONIC  ARTICULAR  RHEUMATISM. 

Etiology. — It  usually  begins  as  a  chronic  affection.  He- 
redity, advanced  years,  and  habitual  exposure  to  cold  and  wet 
are  the  predisposing  factors.  It  rarely  results  from  an  acute 
attack. 

Pathology. — The  fibrous  structures  around  the  joint  are 
greatly  thickened,  so  that  in  long-standing  cases  the  movements 
are  restricted ;  the  neighboring  muscles  are  wasted  from  disuse; 
and  the  nerves  often  reveal  evidences  of  neuritis. 

Symptoms. — Pain,  stiffness,  deformity,  and  creaking  of  the 
joints  are  the  usual  phenomena.  Several  joints  are  commonly 
affected,  and  the  disease  shows  no  predilection  for  any  par- 
ticular joint.  The  symptoms  grow  worse  on  the  approach  of 
stormy  weather,  and  at  such  times  exacerbations  are  liable  to 
occur,  in  which  the  joints  become  swollen  and  tender.  The 
duration  is  indefinite. 

Complications. — Arterial  degeneration  and  chronic  endo- 
carditis. 

Prognosis. — Generally  unfavorable.  Much  relief  may  fol- 
low persistent  and  judicious  treatment,  but  perfect  cure  is 
rarely  attainable. 

Treatment. — Especial  attention  should  be  given  to  the 
hygiene,  particularly  as  regards  diet,  bathing,  clothing,  exer- 
cise, and  occupation.  A  change  of  residence  to  a  dry,  warm, 
and  equable  climate  may  effect  a  cure.  The  tone  of  the  sys- 
tem is  often  reduced ;  hence,  tonics  like  iron,  quinine,  strych- 
nine, and  arsenic  may  be  of  considerable  value.  The  special 
remedies  are  iodide  of  potassium,  guaiac,  sulphur,  salicylic  acid. 


CHRONIC   RHEUMATISM.  311 

and  alkalies  like  the  salts  of  potassium  and  lithium.     Mineral 
waters  are  sometimes  useful. 

^i  Liq.  potass,  arsenitis,  f  ^ij  ; 
Potass,  iodid.,  gii ; 
Syr.  simp.,  f^iij.— M.     (DaCosta.) 
Sig. — A  teaspoonful  three  times  a  day  in  water  after  meals. 

OTHER  MANIFESTATIONS  OF  RHEUMATISM. 

Muscular  Rheumatism  {myalgia,  m.yodynia). — An  affection 
of  the  voluntary  muscles,  characterized  by  pain,  tenderness,  and 
rigidity. 

Types. — Different  names  have  been  applied  according  to 
the  location,  namely  :  Torticollis,  or  wry-neck,  when  it  in- 
volves the  sterno-cleido-mastoid  muscles;  lumbago,  when  it 
involves  the  lumbar  muscles ;  pleurodynia,  when  it  involves 
the  intercostals ;  and  cephalodynia,  when  it  involves  the  oc- 
cipito-frontalis. 

Etiology — The  gouty  or  rheumatic  diathesis  is  a  predis- 
posing cause.  Exposure  to  cold  and  wet  or  muscular  strain 
usually  excites  it. 

Symptoms. — Pain  is  the  chief  symptom ;  it  is  made  worse 
by  use  of  the  muscles,  and  is  associated  with  tenderness  which 
is  especially  marked  at  the  tendinous  origins  and  insertions  of 
the  muscles.  Sometimes  the  muscles  are  contracted  and  rigid  ; 
this  is  particularly  the  case  in  torticollis,  or  wry-neck. 

Torticollis. — The  head  is -fixed  and  inclined  to  one  side; 
every  effort  to  turn  it  is  attended  with  sharp  pain. 

Lumbago. — There  is  a  dull,  aching  pain  across  the  loins. 
Turning  the  body  or  rising  from  the  sitting  posture  causes  an 
exacerbation,  which  is  sometimes  so  severe  that  the  patient 
cries  out.  Care  must  be  taken  to  distinguish  it  from  renal  cal- 
culus, Pott's  disease,  aneurism,  perinephritis,  and  uterine  or 
ovarian  disease. 

Pleurodynia. — The  pain  is  felt  in  the  side,  and  is  increased  by 
deep  breathing,  coughing,  or  twisting  the  body ;  the  respirations 
are  restricted  on  the  affected  side.  There  is  diffuse  tenderness 
to  the  touch.  The  absence  of  fever  and  of  physical  signs  will 
serve  to  distinguish  it  from  pleu7-isy. 


312  CONSTITUTIONAL   DISEASES. 

The  absence  of  tender  spots  where  the  nerves  make  their 
oxit  from  the  muscular  coverings,  the  fact  that  the  pain  does 
not  follow  closely  the  distribution  of  the  nerves,  and  that  the 
pain  is  increased  by  movement,  will  serve  to  distinguish  pleuro- 
dynia from  intercostal  neuralgia. 

Cephalodynia. — This  is  characterized  by  a  superficial  head 
pain  which  is  increased  by  moving  the  scalp  and  which  is 
associated  with  tenderness  on  pressure. 

Prognosis. — Favorable  under  judicious  and  persistent 
treatment. 

Treatment. — The  affected  muscles  should  be  put  at  rest. 
In  pleurodynia  this  is  best  accomplished  by  strapping  the 
affected  side  as  for  fracture  of  the  ribs.  In  lumbago  a  large 
piece  of  adhesive  plaster  may  be  applied  from  the  floating  ribs 
to  the  iliac  crests.  In  mild  cases  the  thorough  application  of 
liniments  containing  chloroform,  aconite,  belladonna,  and  lauda- 
num will  be  all  that  is  required.  In  other  cases  prompt  relief 
often  follows  the  injection  of  morphine  (gr,  |)  with  atropine  (gr. 
l\^),  directly  into  the  muscle.  The  continued  current  is  some- 
times useful.  The  introduction  of  needles,  three  or  four  inches 
long,  deeply  into  the  muscles  (acupuncture)  occasionally  gives 
brilliant  results. 

Internally,  in  acute  cases,  chloride  of  ammonium  (gr.  x  four 
times  daily)  may  prove  efficient.  In  chronic  cases,  iodide  of 
potassium,  guaiac,  colchicum,  and  the  salts  of  lithium  are  the 
remedies  usually  employed.  Gelsemium  pushed  to  its  physio- 
logical limit  has  been  successful  when  other  remedies  have 
failed. 

Neural  Manifestation. — Eheumatism  appears  to  be  a  fre- 
quent cause  of  neuritis. 

Rheumatic  Affections  of  Mucous  Membranes. — It  must  be 
borne  in  mind  that  pharyngitis,  tonsillitis,  laryngitis,  and 
bronchitis  are  sometimes  dependent  upon  a  rheumatic  diathesis. 

Rheumatic  Affections  of  Serous  Membranes. — Endocar- 
ditis, pericarditis,  pleuritis,  iritis,  and  peritonitis  may  be  excited 
by  rheumatism. 

Cutaneous  Manifestations.— Purpura,  urticaria,  and  ery- 
thema nodosum  are  sometimes  associated  with  rheumatism. 


GOUT.  313 

GOUT. 

(Podagra.) 

Definition. — A  general  disease,  characterized  by  varied 
constitutional  disturbances,  the  presence  of  uric  acid  iji  the 
.,blood,  the  depositioii  of  urate  of  soda  in  the  fibrous  structures 
of  the  joints,  and  recurrent  attacks  of  acute  arthritis. 

Etiology. — Middle  and  advanced  life,  male  sex,  heredity, 
a  rich  diet  and  the  indulgence  in  liquors  (especially  malt 
liquors  and  strong  wines),  want  of  exercise,  and  working  in 
lead  are  general  predisposing  factors. 

Pathology. — The  blood  contains  uric  acid,  and  the  fibrous 
structures  of  the  joint  are  the  seat  of  a  deposit  of  urate  of  soda. 
It  is  probable  that  from  defective  nerve-power  the  tissues 
generally  are  unable  to  perfect  the  metabolism  of  nitrogenous 
products  into  urea,  and  that  uric  acid  and  allied  substances  are 
thus  formed.  According  to  Ebstein,  the  uric  acid  excites  a 
necrosis  of  the  cartilages,  whereupon  the  urates  are  crystallized 
out  and  deposited. 

The  cartilages  lose  their  pearly  appearance  and  become 
lustreless  and  infiltrated  with  salts ;  similar  opacities  appear  in 
the  synovial  membrane;  later  rounded  masses  of  urate  of  soda 
(tophi),  varying  in  size  from  a  pea  to  a  marble,  accumulate  in' 
the  tissues  surrounding  the  joint  and  may  ulcerate  through  the 
skin  and  be  discharged.  The  fibrous  structures  become  brit- 
tle and  undergo  destructive  changes.  The  joint  becomes 
irregularly  enlarged,  stiif,  and  finally  anchylosed.  The  meta- 
tarso-phalangeal  joint  of  the  great  toe,  especially  the  right  one, 
is  first  affected,  but  soon  other  small  joints  are  involved. 
Gouty  deposits  are  sometimes  found  along  the  tendons,  beneath 
the  peritoneum,  in  the  perichondrium  of  the  ear,  and  in  the 
tarsal  cartilages. 

The  kidneys  are  generally  the  seat  of  a  chronic  interstitial 
inflammation,  and  section  frequently  reveals  a  deposit  of 
urates  at  the  apices  of  the  pyramids  (gouty  kidney).  The 
arteries  are  sclerosed  and  the  left  side  of  the  heart  is  hypertro- 
phied. 

Symptoms.  Acute  Gout. — Such  prodromes  as  restlessness, 
insomnia,  moroseness,  and  irritability  of  temper  may  precede  the 


314  CONSTITUTIONAL   DISEASES. 

attack.  The  arthritic  phenomena  usually  appear  suddenly  in  the 
early  morning  hours  and  are  characterized  by  pain  and  swell- 
ing in  the  ball  of  the  great  toe.  The  aflPected  joint  is  exqui- 
sitely painful  and  tender,  so  that  the  slightest  pressure  cannot 
be  borne;  it  is  of  a  reddish-purple  color ;  its  surface  is  glazed; 
and  the  neighboring  veins  are  full  and  distinct. 

The  constitutional  symptoms  are  restlessness,  chilliness, 
moderate  fever,  perspiration,  constipation,  and  scanty  high- 
colored  urine,  which  contains,  during  the  paroxysm,  less  urates 
than  in  health.  Towards  daylight  the  symptoms  abate  and 
the  patient  falls  to  sleep.  During  the  day  he  is  comparatively 
comfortable,  but  there  are  severe  exacerbations  for  several 
successive  nights.  At  first  the  attacks  may  be  a  year  apart, 
but  as  they  multiply  the  interval  grows  less,  until  finally  the 
patient  is  seldom  entirely  free  from  suffering. 

Retroeedent  Gout. — This  term  is  applied  to  a  condition  in 
which  the  arthritic  phenomena  suddenly  subside  and  grave 
gastric,  cardiac,  or  cerebral  symptoms  follow. 

Chronic  Gout. — The  joints  are  affected  one  by  one,  and 
become  stiff",  irregularly  enlarged,  and  deformed.  Chalk- 
stones,  or  tophi,  sometimes  ulcerate  their  way  through  the 
skin  and  are  discharged.  Similar  deposits  are  frequently 
found  along  the  tendons  and  in  the  helix  of  the  ear.  The 
constitutional  symptoms  vary  much  in  severity  and  in  char- 
acter. 

Nervous,,  Phenomena. — Vertigo,  headache,  insomnia,  irrita- 
bility of  temper,  and  hypochondriasis.  ''  "-  '■    -    , 

Gastro-intestinal  Phenomena. — Perverted  appetite,  dyspepsia, 
constipation,  and  a  tendency  to  hemorrhoids. 

Urinary  Phenomena. — The  urine  is  at  first  scanty,  high- 
colored,  and  throws  down  an  abundant  brick-dust  sediment ; 
but  ultimately  interstitial  nephritis  develops  and  the  urine 
becomes  pale,  copious,  of  a  low  specific  gravity,  and  contains 
albumin  and  hyaline  casts.  Glycosuria  is  also  frequently  ob- 
served. 

Circulatory  Phenomena. — High  arterial  tension,  accentua- 
tion of  the  aortic  second  sound,  and  later,  arterio-sclerosis  and 
hypertrophy  of  the  left  ventricle. 


GOUT.  315 

Complications  and  Sequels. — Interstitial  nephritis, 
arterio-sclerosis,  hypertrophy  of  the  heart,  apoplexy,  chronic 
bronchitis,  and  cutaneous  eruptions,  especially  eczema. 

Diagnosis. — The  symptoms  of  acute  gout  are  so  charac- 
teristic that  an  error  in  diagnosis  is  scarcely  possible. 

Chronic  gout  may  be  mistaken  for  chronio  rheumatism; 
but  the  former  attacks  especially  the  small  joints ;  it  begins 
in  the  great  toe ;  the  blood  contains  an  excess  of  uric  acid  ; 
and  the  symptoms  are  not  so  much  influenced  by  atmospheric 
changes  as  by  diet. 

Prognosis. — As  regards  the  acute  form,  the  prognosis  is 
good.  The  liability  to  arterial  degeneration  and  to  nephritis, 
and  the  difficulty  in  securing  cooperation  in  carrying  out  the 
treatment  render  the  prognosis  of  chronic  gout  rather  unfavor- 
able. 

Treatment.  The  Acute  Attack. — The  best  remedy  is  col- 
chicum  ;  ten  to  twenty  drops  of  the  wine  well  diluted  should 
be  given  every  two  hours,  and  stopped  as  soon  as  the  symptoms 
subside.  Alkalies  are  valuable  adjuncts,  and  the  salts  of  potas- 
sium or  of  lithium  may  be  given  with  the  colchicum.  Quinine 
is  also  useful ;  it  may  be  given  in  doses  of  five  grains  thrice 
daily.  The  free  use  of  water  should  be  encouraged,  and  a 
water  containing  lithium,  like  the  Buffalo  lithia  water,  may 
be  recommended.  Constipation  should  be  relieved  by  a  full 
dose  of  blue  mass  or  a  saline  draught.  Opium  may  be  required 
for  the  relief  of  the  pain.  The  affected  part  should  be  elevated 
and  wrapped  in  cotton- wool,  or  covered  with  warm  fomenta- 
tions or  with  cloths  soaked  in  lead- water  and  laudanum.  The 
diet  should  be  light  and  non-stimulating. 

Chronic  Gout. — The  diet  must  be  restricted  and  carefully 
arranged  for  each  patient.  Light  meats,  fish,  eggs,  and  oysters 
may  be  used  in  moderation  ;  sweet  fruits  should  be  avoided  ; 
starches  and  sugars  must  be  limited ;  and  the  use  of  liquors 
interdicted.  The  condition  of  the  tongue,  stomach,  and  urine 
will  indicate  the  value  of  this  or  that  dietary.  Mineral  waters 
are  often  serviceable,  and  Carlsbad,  Vichy,  and  Buffalo  lithia 
are  among  the  best.  Their  utility  will  be  enhanced  by  the  addi- 
tion of  a  teaspoonful  of  some  effervescing  salt  of  lithium  to 
each  potation.     A  free  secretion  of  the  skin  should  be  encour- 


316  CONSTITUTIONAL   DISEASES. 

aged  by  frequent  bathing  followed  by  friction.  The  bowels 
should  be  kept  regular  by  salines  or  by  the  occasional  use  of 
a  mercurial  laxative.  Graduated  exercise  holds  a  prominent 
place  in  the  therapy  of  gout.  When  the  digestive  powers  are 
particularly  weak,  mineral  acids  with  strychnine  will  prove 
useful.  General  tonics  are  sometimes  indicated.  The  special 
remedies  are  colchicura,  lithium,  and  iodide  of  potassium. 

^  Vini  sera,  colcliici,  f  Jss  ; 
Potass,  iodidi,  ^ij  ; 
Liq.  potass.,  f^iss ; 

Tr.  zingiberis,  f§ij.— M.     (HoDGSOisr.) 
Sig. — A  teaspoonful  twice  daily  in  warm  water. 

Or  small  doses  of  colchicum  may  be  given  with — 

^  Lithii  benzoat.,  9ij  ; 

Aq.  cinnamon!.,  f|ijss. — M.     (Jaccoud.') 
Sig. — A  teaspoonful  ia  a  wineglass  of  water  every  four  hours. 

The  arthritic  condition  is  best   treated  by  careful  massage 
and  warm  sulphur  baths. 


RHEUMATOID  ARTHRITIS. 

(Arthritis  Deformans,  Rheumatic  Gout.) 

Definition. — A  chronic  a,ffection  of  the  joints  characterized 
by  destruction  of  the  cartilages,  new  osseous  formations,  im- 
mobility, and  deformity. 

Etiology. — Heredity ;  early  adult  life ;  female  sex ;  con- 
tinued emotional  disturbances,  as  anxiety  and  grief;  enfeeble- 
ment  of  health  from  bad  hygienic  environment,  prolonged 
lactation,  and  from^requent  j)regnancies,  are  the  predisposing 
causes.    i-rA'-^'  ;  .  V'-'--r1v(vvv>  ^  wiit  - 

Pathology. — Many  look  upon  rheumatoid  arthritis  as  a 
disease  which  is  related  both  to  gout  and  rheumatism.  Others 
regard  it  as  a  neurosis  and  allied  to  the  arthropathies  which 
are  met  with  in  chronic  affections  of  the  spinal  cord. 

The  cells  of  the  cartilages  and  of  the  synovial  membrane 
proliferate  and  lead  to  villous  or  nodular  outgrowths.  The 
central  portions  of  the  cartilages  ultimately  wear  away  and 
leave  the  bones  exposed.      The   heads   of  the  bones  become 


RHEUMATOID  ARTHRITIS.  317 

smooth  and  hard  like  ivory,  and  thickened  from  exostoses. 
The  synovial  membrane  and  periarticular  tissues  are  likewise 
thickened  and  sometimes  infiltrated  with  bony  products.  The 
surrounding  muscles  are  generally  atrophied.  All  joints  are 
liable  to  be  affected. 

Sy:xipto]SIS. — It  may  be  either  acute  or  chronic^  the  latter 
being  the  more  common  form.  In  the  acute  form  several 
joints  are  simultaneously  involved  ;  they  become  swollen,  pain- 
ful, and  slightly  reddened.  There  is  moderate  fever.  The 
symptoms  soon  subside,  to  reappear,  however,  at  frequent 
intervals. 

In  the  chronic  form,  the  hands,  particularly  the  metacarpo- 
phalangeal joints,  are  usually  first  affected;  then  the  wrists,. 
knees,  toes,  jaws,  and  spine.  Symmetrical  joints  are  usually 
attacked.  The  symptoms  are  :  Swelling,  pain,  immobility,  and 
deformity ;  the  joints  are  stiff  and  creak  when  moved ;  later 
complete  anchylosis  develops ;  the  muscles  waste  and  con- 
tractures increase  the  deformity.  In  advanced  cases  the  fingers 
are  bent  backward,  often  locked,  and  turned  toward  the  ulnar 
side;  the  thighs  are  drawn  up;  the  legs  are  adducted  and 
flexed.     The  patient  maybe  a  helpless  invalid  forruany  years. 

Diagnosis.  Gout. — The  circumstances  under  which  gout 
develops ;  the  history  of  an  acute  attack  in  the  great  toe ;  the 
.  presence  of  uric  acid  in  the  blood ;  the  presence  of  urate  of 
soda  in  the  joints  and  in  the  cartilages  of  the  ear  will  serve  to 
distinguish  the  two  diseases. 

Chronic  Bhemnatism. — Unlike  chronic  rheumatism,  rheu- 
matoid arthritis  begins  in  the  small  joints,  passes  from  joint 
to  joint,  and  leaves  permanent  deformity. 

Prognosis. — Unfavorable.  Sometimes  the  disease  is  local 
and  remains  in  one  joint  (mono-articular  form).  Generally 
several  joints  are  affected,  and  while  judicious  and  persistent 
treatment  may  retard  the  progress  of  the  disease,  a  cure  is 
rarely  attainable. 

Treatment. — Good  hygiene.  Tonics  like  iron,  arsenic, 
phosphorus,  and  cod-liver  oil  are  useful.  The  most  good  is 
to  be  expected  from  local  treatment,  which  consists  of  massage, 
electricity,  steam  baths,  and  inunctions  of  preparations  con- 
taining iodine  or  mercury. 


318  CONSTITUTIONAL  DISEASES. 

RICKETS. 

(Rachitis.) 

Definition. — ^A  constitutional  disease  of  early  childhood, 
characterized  chiefly  by  defective  nutrition  of  the  osseous 
structures. 

Etiology. — Rickets  is  rarely  congenital ;  it  usually  de- 
velops between  the  first  and  second  years.  Poverty,  artificial 
feeding,  and  bad  hygienic  conditions  are  the  predisposing 
causes. 

Pathology. — The  most  marked  changes  are  observed  in 
the  long  bones  and  ribs.  The  cartilaginous  lamina  between 
the  epiphysis  and  the  shaft  are  considerably  thickened,  and 
are  spongy  and  irregular  in  outline ;  microscopic  examination 
reveals  an  excessive  proliferation  of  the  cartilage-cells  with 
scanty  calcification.  The  periosteum  is  thickened  and  highly 
vascular,  and  when  stripped  off'  soft  porous  bone  is  exposed. 
The  bones  are  soft,  being  extremely  deficient  in  lime-salts ; 
when  ossification  finally  results  the  bones  become  heavy,  large, 
and  irregular  in  outline ;  these  changes  correspond  to  the  clinical 
phenomena — bow-legs,  knock-knees,  spinal  curvature,  pigeon- 
breast,  and  square  cranium. 

The  liver  and  spleen  are  often  considerably  enlarged. 

Symptoms. — The  early  symptoms  are :  Restlessness  and 
slight  fever  at  night ;  free  perspiration  about  the  head ;  dif- 
fuse soreness  and  tenderness  of  the  body ;  pallor ;  slight  diar- 
rhoea ;  enlargement  of  the  liver  and  spleen  ;  delayed  dentition 
and  the  eruption  of  badly- formed  teeth. 

Skeletal  Phenomena. — The  head  is  large  and  more  or  less 
square  in  outline ;  careful  palpation  may  detect  soft  areas. 
The  sides  of  the  thorax  are  flattened ;  the  sternum  is  promi- 
nent ;  nodules  can  be  felt  at  the  sternal  ends  of  the  ribs — 
"  rachitic  rosary"  ;  there  may  be  a  distinct  transverse  groove  at 
the  level  of  the  ensiform  cartilage;  the  spinal  column  is  fre- 
quently curved  antero-posteriorly  or  laterally  ;  the  long  bones 
are  curved  and  prominent  at  their  extremities. 

Complications. — Green-stick  fractures,  convulsions,  laryn- 
gismus stridulus,  paresis  of  the  extremities,  and  acute  pulmo- 


LITH^MIA.  319 

nary  diseases.  In  women  the  rachitic  pelvis  may  seriously 
complicate  labor. 

Peognosis. — Rachitis  does  not  kill  directly,  but  death  is  not 
uncommon  from  intercurrent  disease.  Under  good  hygienic 
conditions  recovery,  with  more  or  less  deformity,  generally 
follows. 

Treatment. — The  general  nutrition  must  be  improved  by 
placing  the  child  under  the  best  hygienic  conditions.  Eggs, 
pure  milk,  malt,  and  broths  should  be  recommended.  Cod- 
liver  oil  is  a  valuable  nutrient  tonic.  Iron  is  indicated  for 
the  angemia.  The  lack  of  calcareous  material  in  the  bones 
should  be  supplied  by  the  administration  of  phosphorus  and 
lime-salts. 

R     Syr.  ferri  iodid.,  f^iss; 
Mist.  ol.  morrhuse  et 

Lactophos.  calcis,  q.  s.  ad  f^iij. — M.    (Starr.) 
Sig. — From  one-half  to  a  teaspoonful  three  times  a  day. 

B    Elixir,  phosphori,  f^iiiss ; 
01.  morrhuse,  f^ij  ; 
Pulv.  acaciae,  q.  s.; 
01.  sassafras,  gtt.  XV ; 
Aquse  q.  s.  ad  f^iV. — M. 
Sig.-— One  to  two  teaspoonfuls  three  times  a  day. 


LITH^MIA. 

(Lithic-acid  Diathesis,  Uric-acid  Diathesis,  Latent  Gout.) 

Definition. — A  constitutional  disease  dependent  upon  mal- 
assimilation  of  nitrogenous  products  and  the  formation  of  uric 
acid  and  allied  substances  instead  of  urea,  and  characterized 
by  an  excess  of  nric  acid  in  the  urine,  and  varied  digestive, 
circulatory,  and  nervous  phenomena. 

Etiology. — Gout  with  an  acute  arthritic  expression  is  un- 
common in  A  merica,  but  latent  gout,  or  litheemia,  is  extremely 
common.  Impaired  digestion,  insufficient  exercise,  mental 
strain,  and  over-eating  are  the  usual  causes. 

Symptoms.  Gastro-intestinal  Phenomena. — The  tongue  is 
generally  coated  and  the  breath  heavy  ;  the  appetite  is  variable, 
sometimes  it  is  lost,  at  others  it  is  inordinate ;  acid  eructations, 


320  ■      CONSTITUTIONAL    DISEASES. 

"  heartburn,"  and  flatulence  are  frequent  gastric  symptoms ; 
the  bowels  are  usually  constipated. 

Urinary  Phenomena. — The  urine  is  scanty,  high-colored,  of 
high  specific  gravity  (1025  - 1035),  and  on  standing  throws 
down  an  abundant  brick-dust  sediment.  The  solids  render 
the  urine  irritating,  so  that  dull  aching  in  the  loins  and  burn- 
ing in  the  penis  after  micturition  are  common  symptoms.  A 
trace  of  sugar  is  sometimes  detected  on  chemical  examination. 
The  urine  often  stains  the  clothes  red. 

Circulatory  Phenomena. — High  arterial  tension,  accentua^ 
tion  of  the  aortic  second  sound,  and  a  tendency  to  atheroma. 

Nervous  Phenomena. — Headache,  vertigo,  disturbed  sleep, 
tinnitus  aurium,  depression  of  spirits,  failure  of  memory,  loss 
of  energy,  irritability,  and  neuralgic  pain  in  various  parts  of 
the  body. 

Sequelae.  —  Arterial  degeneration,  interstitial  nephritis, 
hepatic  cirrhosis,  gastritis,  renal  or  vesical  calculi. 

Diagnosis. — This  rests  on  the  general  symptoms  and  the 
analysis  of  the  urine. 

Pkognosis.  —  Favorable  under  prolonged  and  judicious 
treatment. 

Treatment. — Special  attention  must  be  given  to  the  diet. 
It  is  a  mistake  to  cut  oflP  all  nitrogenous  foods,  for  often  the  chief 
diflSculty  is  in  digesting  the  starches  and  sugars.  Light  meats, 
green  vegetables,  eggs,  and  oysters  are  admissible.  The  use 
of  fats,  heavy  meats,  sweets,  starches,  and  alcoholic  beverages 
must  be  restricted.  Xext  to  diet,  regular  exercise  is  the  most 
important  therapeutic  measure ;  the  patient  must  eat  less  or 
burn  up  more  material,  and  the  chief  stimulant  of  tissue-metab- 
olism is  exercise.  A  change  of  scene  may  effect  brilliant  results. 
Frequent  bathing  with  salt  water  folloAved  by  friction  is  a 
valuable  adjunct.  When  the  gastric  digestion  is  weak,  mineral 
acids,  strychnine,  and  pepsin  are  useful  remedies.  The  salts  of 
potassium  and  lithium  are  solvents  of  uric  acid  ;  citrate  of 
lithium  (gr.  xx),  benzoate  of  lithium  (gr.  v),  or  citrate  of  potas- 
sium (gr.  xx),  may  be  given,  well  diluted,  two  hours  after 
meals.  Mineral-waters  containing  these  salts  may  be  recom- 
mended. The  bowels  should  be  kept  regular  by  some  simple 
laxative. 


DIABETES.  321 

DIABETES. 

(Diabetes  Mellitus.) 

Definition. — A  nutritional  disease,  characterized  by  the 
persistent  presence  of  sugar  in  the  urine,  polyuria,  and  loss  of 
flesh  and  strength. 

Etiology. — Heredity,  adult  life,  male  sex,  the  Hebrew 
race,  prolonged  mental  anxiety,  and  dietetic  errors  are  pre- 
iisposing  causes.     It  rarely  follows  injury  of  the  brain  or  cord. 

Pathology. — The  lesions  found  after  death  have  been  so 
varied  that  the  condition  which  is  really  responsible  for  diabetes 
is  still  undetermined.  Puncture  of  the  floor  of  the  fourth 
ventricle  will  produce  glycosuria,  but  the  cases  are  rare  in 
which  lesions  of  this  region  have  been  found  after  death.  In 
a  notable  number  of  cases  the  pancreas  is  the  seat  of  cirrhosis 
and  of  fatty  degeneration,  but  the  relation  of  this  condition  to 
diabetes  is  still  unknown.  The  liver  is  frequently  enlarged  and 
the  seat  of  degeneration  changes.  The  kidneys  are  enlarged 
and  often  reveal  evidences  of  parenchymatous  inflammation. 

According  to  one  view,  diabetes  has  its  origin  in  the  sympa- 
thetic nervous  system,  and  results  from  a  vaso-motor  dilatation 
of  the  hepatic  vessels  causing  a  disturbance  of  the  glycogenic 
function  of  the  liver  and  the  discharge  of  glucose  in  the  urine. 

According  to  another  theory,  diabetes  results  from  a  func- 
tional or  organic  disease  of  those  organs,  particularly  the  pan- 
creas and  liver,  which  are  engaged  in  the  assimilation  of 
starches  and  sugars. 

Symptoms.  Urinary  Phenomena. — The  urine  is  increased 
in  quantity,  the  amount  varying  from  three  or  four  pints  to  as 
many  gallons ;  its  color  is  pale ;  its  specific  gravity  ranges 
from  1015  to  1050 ;  it  has  a  sweetish  taste  and  an  aromatic 
odor.  In  summer  it  attracts  flies  and  rapidly  ferments.  It 
may  leave  a  whitish  residue  on  the  clothes.  The  percentage  of 
glucose  varies  from  a  half  per  cent,  to  ten  per  cent. ;  the  total 
amount  excreted  in  twenty-four  hours  varies  from  a  few  ounces 
to  a  pound  or  more. 

General  Phenomena. — There  is  loss  of  flesh  and  strength  ; 
the  temperature  is  normal  or  subnormal ;  the  appetite  is  often 
inordinate,    and    the    thirst    unquenchable;    the    tongue    is 


322  CONSTITUTIONAL   DISEASES. 

often  fissured  and  beefy-red ;  the  bowels  are  usually  consti- 
pated.    The  muscles  are  sometimes  the  seat  of  painful  cramps. 

Cutaneous  Phenomena. — The  skin  is  harsh  and  dry,  and 
frequently  the  seat  of  intense  itching.  Pruritus  is  especially 
observed  at  the  genitalia,  and  this  may  be  the  first  subjective 
symptom. 

Nervous  Phenomena. —  Headache,  depression  of  spirits, 
diminished  or  lost  patellar  reflexes,  impaired  sexual  power, 
dimness  of  vision,  and  neuralgia. 

The  duration  varies  from  a  few  weeks  in  the  acute  form  to 
many  years  in  the  chronic  form. 

Complications.  —  Pulmonary  tuberculosis,  pneumonia, 
gangrene  of  the  lung ;  defective  vision  from  soft  cataract, 
retinitis  or  atrophy  of  the  optic  nerve ;  cutaneous  lesions,  as 
boils,  eczema,  carbuncles,  and  gangrene;  nephritis;  neuritis 
and  diabetic  coma,  or  aeetoncemia. 

This  last  condition  is  characterized  by  epigastric  pain,  dys- 
pnoea, a  fruity  odor  of  the  breath,  headache,  delirium,  stupor, 
and  coma ;  it  probably  results  from  the  presence  of  diacetic 
and  oxybutyric  acids  in  the  blood. 

Diagnosis. — Care  must  be  taken  to  distinguish  simple  gly- 
cosuria from  diabetes.  The  former  is  recognized  by  being 
transient,  and  unassociated  with  the  constitutional  symptoms  of 
diabetes. 

Pruritus  and  apparently  causeless  loss  of  flesh  and  strength 
should  lead  to  a  suspicion  of  diabetes. 

Prognosis. — The  younger  the  patient,  the  stronger  the 
hereditary  tendency,  the  larger  the  amount  of  sugar  excreted, 
the  less  the  glycosuria  can  be  controlled  by  diet  alone,  the 
graver  the  prognosis.  On  the  other  hand,  when  it  occurs  after 
middle  life  in  association  with  a  gouty  diathesis,  and  the  gly- 
cosuria is  not  pronounced,  the  prognosis  for  a  long  duration  is 
comparatively  favorable.     Absolute  cure  is  rarely  attainable. 

Treatment.  Dietetic  Treatment. — Sugars  and  starches 
must  be  restricted.  Since  the  patient's  appetite  is  often  inordi- 
nate, it  is  necessary  to  regulate  the  quantity  and  character  of 
those  foods  which  are  recognized  as  admissible.  The  following 
foods  may  be  included  in  the  dietary  : — 


DIABETES.  323 

Animal  Foods. — Meats  of  various  kinds  (except  liver), 
game,  light  broths  and  soups,  fish,  and  eggs. 

Vegetables. — Celery,  lettuce,  cauliflower,  tomatoes,  mush- 
rooms, string-beans,  young  onions,  olives,  water-cress,  and 
spinach. 

Beverages. — Buttermilk,  skim  milk,  sour  wines  (Rhine 
wines),  carbonated  waters,  and  coffee  and  tea  without  sugar. 

Relishes. — Nuts  of  all  kinds  (except  chestnuts),  cream  cheese, 
and  pickles. 

Bread. — Bread  made  of  gluten,  bran  flour,  or  almond  flour. 
It  should  be  borne  in  mind  that  all  the  gluten  flours  are  rich 
in  starch. 

Fruits. — Cranberries,  sour  cherries,  limes,  lemons,  and  red 
currants. 

Substitutes  for  Sugar, — Saccharin  and  glycerin. 

The  following  foods  should  be  avoided :  Liver,  oysters, 
wheat  bread,  biscuits,  pastry,  potatoes,  beets,  carrots,  peas, 
turnips,  parsnips,  sweet  fruits,  rice,  barley,  tapioca,  corn-starch, 
corn-meal,  chocolate,  cocoa,  syrups,  preserves,  and  most  liquors. 

Hygienie  Treatment. — Graduated  exercise  ;  frequent  bathing 
with  salt  water  followed  by  friction ;  the  use  of  flannel 
underclothing ;  plenty  of  rest  and  sleep ;  and,  if  possible,  a 
change  of  scene. 

Medicinal  Treatment. — Tonics  like  iron,  arsenic,  strychnine, 
alcohol,  and  cod-liver  oil  are  often  indicated.  The  special  reme- 
dies are  opium" and  its  alkaloids — morphine  and  codeine — bro- 
mide of  arsenic,  ergot,  antipyrin,  salicylate  of  sodium,  and  alka- 
lies. Opium  is  generally  the  most  useful  drug;  it  should  be 
given  in  small  doses  gradually  increased  until  the  patient  takes 
five  or  six  grains  daily.  Codeine  (gr.  ^  increased  to  gr.  vj  a 
day)  has  been  thought  preferable  to  either  opium  or  morphine, 
but  according  to  the  clinical  experiments  of  Bruce  and  Osier, 
morphine  is  much  more  reliable.  The  latter  may  be  employed 
in  doses  of  one-fourth  of  a  grain  three  or  four  times  daily. 
The  bromide  of  arsenic  is  sometimes  of  decided  value ;  it  may 
be  given  in  the  following  solution : — 

^  Liq.  arsenici  brom.,  f^j. 
Sig. — Two  to  five  drops  well  diluted  after  meals. 

In  gouty  patients  a  course  of  Carlsbad  water  with  salicylate 


324  CONSTITUTIONAL   DISEASES. 

of  sodium  (gr.  iij-v  thrice  daily)  and  antipyrin  (gr.  v-x  thrice 
daily)  may  be  recommended,  or : — 

^  Sodii  salicylat.,  ^iij  ; 

Liq.  potass,  arseuitis,  f^j  ; 
Grlycerini,  f5J ; 

Aq.  cinuamomi,  ad  f;^iij.— M.     (J,  C.  Wilson.) 
Sig.— A  teaspoonful  to  a  dessertspoonful  thrice  daily 

Diabetic  coma  is  always  fatal,  bnt  inhalations  of  oxygen 
or  the  subcutaneous  injection  of  large  quantities  of  normal 
saline  solution  at  intervals  may  give  a  few  hours'  respite,  in 
which  consciousness  returns. 

DIABETES  INSIPIDUS. 

Definition. — A  chronic  condition  characterized  by  the 
excretion  of  large  quantities  of  pale,  limpid  urine  of  low  specific 
gravity  and  free  from  albumin  and  sugar. 

Etiology. — Diabetes  insipidus  must  be  distinguished  from 
the  simple  polyuria  observed  in  chronic  renal  disease,  in  cer- 
tain diseases  of  the  brain,  and  in  some  cases  of  hysteria. 

Diabetes  insipidus  sometimes  develops  without  obvious 
cause.  It  is  more  common  in  the  young,  and  more  males  are 
attacked  than  females.  It  is  occasionally  hereditary.  It  has 
been  induced  by  injury  and  by  certain  diseases  of  the  brain. 
Profound  emotional  disturbance  has  excited  it.  Syphilis, 
overwork,  and  the  free  use  of  cold  water  when  the  body  has 
been  overheated,  are  reputed  causes. 

Pathology. — Little  is  known  of  the  pathology.  The 
kidneys  are  frequently  enlarged  and  congested,  and  the  ureters 
dilated. 

The  theory  which  is  generally  accepted  as  accounting  for 
the  polyuria,  is  that  it  is  due  to  a  vaso-motor  paresis  of  the 
renal  vessels,  which  permits  a  free  transudation  of  liquid. 

Symptoms. — The  disease  may  begin  insidiously  or  abruptly; 
the  latter  is  the  rule.  The  urine:  The  quantity  is  increased, 
often  as  much  as  eight  or  ten  quarts  being  excreted  in  the 
twenty-four  hours ;  it  is  pale,  and  resembles  water ;  it  has  a 
specific  gravity  of  1002-1005.  The  total  amount  of  solids  is 
not  diminished.  .Albumin  and  sugar  are  generally  absent, 
though  there  may  be  a  trace  of  the  latter. 


SCURVY.  325 

General  Symptoms. — Insatiable  thirst ;  good  appetite ;  a 
harsh,  dry  skin  ;  a  dry  tongue  ;  constipation  ;  mental  apathy  ; 
and  emaciation. 

Duration. — When  unassociated  with  organic  disease  the 
duration  may  be  indefinite. 

Complications. — These  are  much  less  common  than  in 
diabetes  mellitus.  Cataract,  pruritus,  boils,  and  tuberculosis 
have  been  observed. 

Diagnosis.  Diabetes  Mellitus. — The  low  specific  gravity 
of  the  urine  and  the  absence  of  sugar  will  serve  to  distinguish 
diabetes  insipidus  from  diabetes  mellitus. 

Interstitial  Nephritis, — The  presence  of  albumin,  hyaline 
casts,  high  arterial  tension,  accentuation  of  the  aortic  second 
sound,  and  the  cardiac  hypertrophy  Mill  indicate  nephritis. 

Symptomatic  Polyuria. — The  history  and  a  careful  physical 
examination  will  usually  prevent  an  error  in  diagnosis. 

Prognosis. — Usually  unfavorable.  A  permanent  cure  is 
sometimes  effected.  Death  results  from  exhaustion,  or  more 
frequently,  from  some  intercurrent  disease. 

Treatment. — The  hygienic  treatment  suggested  for  diabetes 
mellitus  is  applicable  in  this  disease.  No  benefit  is  derived 
from  cutting  off  the  amount  of  water  drunk.  Lemonade  and 
other  acid  drinks  may  serve  to  lessen  the  amount  of  liquid 
consumed. 

The  remedies  recommended  are  ergot,  strychnine,  opium, 
valerian,  and  nitric  acid.  Galvanism — one  pole  applied  to 
the  neck  and  the  other  to  the  loins — has  given  good  results. 
When  syphilis  is  suspected,  the  mercurials  and  iodides  may  be 
administered  freely  with  good  hopes  of  a  successful  issue. 

]^  Pulv.  opii,  gr.  iv ; 

Acid,  gallici,  3ij.— M.     (H.  C.  Wood.) 
Ft.  in  chart.  ISTo.  xii. 
Sig. — One,  three  or  four  times  daily. 

SCURVY. 

(Scorbutus.) 

Etiology. — Lack  of  fresh  vegetables  and  bad  hygienic 
surroundings  are  the  predisposing  causes. 


326  CONSTITUTIONAL   DISEASES. 

Pathology.  —  The  pathogenesis  of  scurvy  is  unknown. 
Fatty  degeneration  from  the  anaemia,  and  widespread  ecchy- 
moses  are  found  after  death. 

Symptoms. — The  general  manifestations  of  ansemia,  with 
great  weakness ;  spongy,  bleeding  gums,  fetor  of  the  breath, 
and  loosening  of  the  teeth  ;  subcutaneous  ecchymoses,  and 
hemorrhages  from  the  mucous  membranes  ;  and  finally,  a  pain- 
ful, brawny  induration  of  the  muscles  due  to  a  sanguineous 
exudation. 

An  infantile  form  of  scurvy  {Barlow's  Disease)  sometimes 
follows  the  prolonged  use  of  condensed  milk,  sterilized  milk,  or 
proprietary  foods.  The  characteristic  symptoms  are  :  Asthe- 
nia, anteraia,  immobility  of  the  legs,  pseudo-paralysis,  extreme 
tenderness,  swelling  without  pitting,  thickening  of  the  bones 
from  subperiosteal  hemorrhage,  ecchymoses,  occasionally  spongy 
gums,  and  a  tendency  to  epiphyseal  fractures. 

Prognosis. — Favorable  in  its  earlier  stages. 

Treatment. — Fresh  vegetables  and  the  free  use  of  lemon- 
juice.  Iron  in  moderate  doses.  Weak  solutions  of  chlorate  of 
potassium  or  nitrate  of  silver  may  be  applied  to  the  bleeding 
gums.  In  infantile  scurvy  good  results  follow  the  use  of  fresh 
milk,  beef-juice,  and  orange-juice. 

HEMOPHILIA. 

(Bleeder's  Disease,  Hemorrhagic  Diathesis.) 

Definition. — An  hereditary  disease,  characterized  by  a 
tendency  to  bleed  excessively  from  slight  wounds,  or  even 
spontaneously. 

Etiology. — The  great  cause  is  heredity.  It  is  more  com- 
mon in  males,  but  is  usually  transmitted  by  females,  even  by 
those  who  are  not  themselves  afflicted. 

Pathology. — Unknown.  In  some  instances  the  arteries 
have  been  found  smaller  than  normal,  with  their  walls  thin 
and  degenerated. 

Symptoms.  —  The  chief  symptom  is  free  and  persistent 
bleeding  after  trivial  injury.  Spontaneous  hemorrhages  from 
mucous  membranes  of  the  nose,  stomach,  bowel,  etc.,  and  sub- 
cutaneous extravasations  are  quite  common.     The  only  other 


PURPURA    HEMORRHAGICA.  327 

symptom  is  a  peculiar  inflammation  of  the  joints,  resembling 
rheumatism. 

Prognosis. — Unfavorable.  Grandidier  states  that  one-half 
die  before  the  eighth  year,  and  less  than  one-eighth  survive 
their  twenty-first.    In  some  instances  the  tendency  is  outgrown. 

Treatment. — Protective  and  palliative.  The  bleeding  will 
demand  the  application  of  cold  compresses  and  styptics,  and 
the  internal  use  of  haemostatics  like  ergot,  hamamelis,  or  erig- 
eron.     The  resulting  anaemia  will  be  benefited  by  iron. 

PURPURA  HE3IORRHAGICA. 

(Morbus  Maculosus  Werlhofii.) 

Definition. — A  condition  arising  without  obvious  cause, 
and  characterized  by  extravasation  of  blood  in  the  skin  and 
bleeding  from  the  mucous  membranes. 

Etiology. — Bad  hygiene,  early  life,  and  female  sex  exert 
some  predisposing  influence ;  but  it  may  occur  at  any  age 'and 
in  the  most  robust  of  either  sex.    A  microorganismal  cause  has  . 
been  suggested. 

Pathology. — Unknown. 

Symptoms.  —  The  onset  may  be  marked  by  some  fever, 
headache,  malaise,  and  pain  in  the  limbs  ;  but  these  symptoms 
may  be  absent,  and  the  disease  ushered  in  with  a  copious  crop 
of  small  hemorrhages  into  the  skin,  followed  by  bleeding  from 
the  mucous  membranes.  Anaemia  and  its  associated  phenomena 
develop  in  severe  cases. 

Diagnosis. — The  absence  of  high  fever  and  nervous  symp- 
toms will  separate  it  from  typhus  fever  and  cerebrospinal 
meningitis.  The  history  and  the  absence  of  spongy  gums  and 
of  brawny  induration  of  the  muscles  will  separate  it  from 
scurvy.  Previous  health  and  the  absence  of  hereditary  ten- 
dency separate  it  from  hceniopjhilia. 

Prognosis. — Depends  on  the  severity.  Mild  cases  recover 
in  from  one  to  two  weeks ;  severe  cases  may  prove  fatal  in  a 
few  days  from  exhaustion  or  hemorrhage  into  the  brain.  Re- 
lapses are  common. 

Treatment. — Rest.  Light,  nutritious  food.  Arsenic, 
iron,  turpentine,  and  the  fluid  extract  of  hamamelis  are  the 
most  serviceable  remedies. 


DISEASES 


NERVOUS  SYSTEM. 


DISTURBANCES  OF  MOTION. 

These  cousist,  for  the  most  part,  of  loss  of  power,  or  para- 
lysis, and  manifestation  of  motor  excitation,  such  as  convul- 
sions, choreiform  movements,  and  tremors. 

Paralysis. 

The  paralysis  may  be  irregularly  distributed,  or  it  may  in- 
volve a  single  member,  when  it  is  termed  monoplegia  ;  a  lateral 
half  of  the  body,  when  it  is  termed  hemiplegia  ;  or  the  body 
from  the  waist  down,  when  it  is  termed  paraplegia. 

Irregular  paralysis  may  result  from  : — 

1.  Disseminated  lesions  in  the  motor  areas  of  the  brain, 
which  are  commonly  syphilitic. 

2.  Lesions  in  the  basal  ganglia — pons,  crura  cerebri,  medulla, 
when  it  is  often  associated  with  headache,  vomiting,  vertigo, 
and  optic  neuritis. 

3.  Acute  poliomyelitis.  This  develops  abruptly  ;  it  occurs 
in  young  children  ;  and  it  is  followed  by  rapid  improvement  in 
some  muscles  and  permanent  atrophy  and  paralysis  in  others. 

4.  Chronic  poliomyelitis.  This  develops  in  middle  life ; 
begins  in  the  small  muscles  of  the  hand ;  is  associated  with 
atrophy ;   and  progresses  very  slowly. 

5.  Idiopathic  muscular  atrophy.  This  commonly  develops 
during  adolescence ;  involves  the  muscles  of  the  arm,  shoulder, 

(  328  ) 


DISTURBANCES   OF   MOTION.  329 

buttocks,  aud  thigh ;  is  associated  with  atrophy ;  and  can  be 
frequently  traced  to  heredity. 

6.  Pseudo-muscular  hypertrophy.  This  develops  in  child- 
ren ;  is  associated  with  enlargement  of  the  aflPected  muscles ; 
and  can  be  frequently  traced  to  heredity. 

7.  Multiple  neuritis.  This  is  recognized  by  the  history, 
pain,  disturbances  of  sensation,  and  tenderness  over  the  nerve- 
trunks. 

8.  Syringo-myelia.  This  is  rare ;  develops  during  ado- 
lescence ;  and  is  recognized  by  pains,  atrophy  of  the  affected 
muscles,  a  spastic  condition  of  the  paralyzed  members,  and  a 
loss  of  thermic  and  jjainful  sensations,  while  tactile  sensation 
is  retained. 

Monoplegia  may  result  from  : — 

1.  A  focal  lesion  in  the  cortical  area  of  the  brain.  This 
may  be  recognized  by  the  history,  the  absence  of  wasting,  of 
sensory  disturbances,  and  of  the  reactions  of  degeneration. 

2.  A  lesion  of  the  peripheral  nerve,  from  traumatism,  neu- 
ritis, or  the  pressure  of  a  tumor.  Brachial  monoplegia  fre- 
quently results  from  the  pressure  of  the  head  on  the  arm 
during  sleep.  Monoplegia  of  peripheral  origin  is  recognized 
by  the  history,  the  wasting,  the  sensory  disturbances,  and  the 
presence  of  reactions  of  degeneration. 

3.  Hysteria.  This  may  be  recognized  by  the  history,  sex, 
and  temperament ;  the  paroxysmal  character  of  the  paralysis ; 
the  disturbances  of  sensation ;  and  contractures  without  atrophy 
or  electrical  disturbances. 

Facial  monoplegia  may  result  from  a  small  lesion  in  the 
fii.cial  centre  of  the  cortex  or  in  the  medulla ;  or  from  involve- 
ment of  the  nerve  in  the  canal  of  the  temporal  bone;  or  after 
its  exit  from  the  stylo-mastoid  foramen. 

Facial  diplegia  (double  facial  paralysis)  generally  results 
from  a  lesion  at  the  base  of  the  brain. 

Hemiplegia  may  result  from  : — 

1 .  A  diffuse  lesion  of  the  motor  cortex.  The  paralysis  is 
on  the  opposite  side  of  the  body  and  is  unassociated  with 
anaesthesia. 

2.  A  lesion  of  the  internal  capsule  or  the  adjacent  ganglia 
(corpus   striatum   and    optic   thalamus).      This  is   the  most 


330  DISEASES   OF   THE   NERVOUS   SYSTEM. 

common  seat  of  hemorrhage ;  the  paralysis  is  on  the  opposite 
side  of  the  body  and  is  uuassociated  with  anaesthesia. 

3.  A  lesion  of  the  crus  cerebri.  This  frequently  produces 
hemiplegia  and  hemiansesthesia  on  the  opposite  side,  and  par- 
alysis of  the  oculo-motor  nerve  on  the  side  of  the  lesion,  indi- 
cated by  dilated  pupil,  strabismus,  and  ptosis. 

4.  A  lesion  of  the  pons.  This  frequently  produces  hemi- 
plegia and  hemiansesthesia  on  the  opposite  side,  and  facial 
paralysis  on  the  side  of  the  lesion. 

5.  A  lesion  in  the  medulla.  This  is  rare,  and  is  associated 
with  paralysis  of  the  cranial  nerves,  difficult  articulation,  car- 
diac and  respiratory  disturbances,  and  vomiting. 

6.  A  unilateral  lesion  high  in  the  cord  (very  rare).  This 
produces  a  spastic  paralysis  on  the  side  affected,  and  hemianses- 
thesia on  the  opposite  side  ("  Brown-Sequard's  paralysis"). 

7.  Hysteria.  This  may  be  recognized  by  the  history,  sex, 
and  temperament;  by  being  frequently  paroxysmal;  by  its 
association  with  sensory  disturbances  ;  by  the  absence  of  wast- 
ing and  of  abnormal  electrical  reactions;  and  by  the  escape  of 
the  facial  muscles. 

Paraplegia  may  result  from  : — 

1.  Hemorrhage  into  the  cord  at  the  dorsal  region.  The 
paralysis  develops  abruptly,  and  is  associated  with  complete 
anaesthesia  and  involvement  of  the  bladder  and  rectum. 

2.  Hemorrhage  into  the  membranes  of  the  cord.  The  par- 
alysis develops  rapidly,  but  more  slowly  than  the  preceding ; 
is  associated  with  intense  tearing  pains  and  incomplete  anses- 
thesia. 

3.  Some  forms  of  multiple  neuritis.  This  is  recognized  by 
the  pains,  the  disturbances  of  sensation,  the  tenderness  over  the 
nerve-trunks,  and  the  absence  of  "  girdle  pain"  and  sphincter 
involvement. 

4.  Fracture  of  the  vertebrae. 

5.  Acute  myelitis.  The  paralysis  develops  in  the  course  of 
a  few  days,  and  is  associated  with  ansesthesia,  bedsores,  involve- 
ment of  the  bladder  and  rectum,  loss  of  reflexes,  and  wasting 
of  the  muscles. 

6.  Landry's  disease  (acute  ascending  paralysis).  This  de- 
velops in  the  course  of  a  few  days,  and  is  uuassociated  with 


DISTURBANCES   OF   MOTION.  331 

anaesthesia,  wasting  of  the  muscles,  bedsores,  or  sphincter  in- 
volvement. 

7.  Chronic  myelitis.  This  develops  over  several  years,  and 
is  associated  with  numbness  and  tingling,  increased  reflexes, 
involvement  of  the  bladder  and  rectum,  and  anaesthesia. 

8.  Compression  of  the  cord  from  morbid  growths,  aneurism, 
or  spinal  caries.  This  may  be  recognized  by  the  history,  the 
symptoms  of  the  primary  disease,  the  anaesthesia  or  hyper- 
sesthesia,  and  the  intense  pains  radiating  along  the  line  of  the 
spinal  nerves. 

9.  Lateral  sclerosis.  This  develops  slowly  and  is  associated 
with  a  spastic  condition  of  the  muscles  and  with  increased 
reflexes,  and  lacks  sensory  disturbances. 

10.  Injury  of  the  brain  in  delivery  (spastic  paraplegia  of 
infants).  The  symptoms  resemble  lateral  sclerosis,  and  are 
often  associated  with  imbecility  or  idiocy. 

11.  Hysteria.  This  may  be  recognized  by  the  history, 
sex,  and  temperament ;  by  being  frequently  paroxysmal ; 
and  by  the  absence  of  wasting  and  of  abnormal  electrical 
reactions. 

12.  Caisson  disease  (divers'  paralysis).  The  history  will 
establish  the  diagnosis. 

Convulsions. 

A  convulsion  is  a  condition  in  which  there  are  excessive 
muscular  contractions,  continued  or  intermittent,  dependent 
upon  an  involuntary  discharge  of  motor  impulses  from  the 
nerve-centres. 

Intermittent  contractions  are  termed  clonic  ;  continued  con- 
tractions, tonic. 

Convulsions  may  be  general  or  local.  The  term  sjjasm  is 
sometimes  applied  to  the  latter. 

Varieties  of  Convulsions. — Three  varieties  are  frequently 
made  :  (1)  Epileptiform  ;  (2)  tetanic ;  (3)  hysteroidal. 

Epileptiform  Convulsions. — In  this  form  there  is  uncon- 
sciousness, and  the  movements  are  for  the  most  part  clonic. 
Epileptiform  convulsions  may  result  from  : — 


332  DISEASES   OF   THE   NERVOUS  SYSTEM. 

1.  Idiopathic  ej^ilepsy.  This  condition  usually  develops 
before  puberty,  and  the  convulsions  are  general  and  are 
unassociated  with  any  definite  cause. 

2.  Organic  brain  disease.  In  this  condition  there  may  be 
a  history  of  syphilis  or  of  injury ;  the  convulsions  may  be 
local,  or  begin  as  such  and  become  general ;  and  there  may  be 
concomitant  symptoms  of  cerebral  disease. 

3.  Toxic  agents  in  the  blood.  Alcoholism,  the  infectious 
fevers,  and  uraemia  are  frequently  associated  with  convulsions. 

4.  Reflex  irritation.  Such  convulsions  are  usually  observed 
in  young  children,  and  result  from  gastric  irritation,  an  ad- 
herent prepuce,  intestinal  parasites,  or  teething.  Convulsive 
seizures  sometimes  result  from  the  injection  of  substances  into 
the  pleural  sac  for  the  cure  of  hydrothorax. 

5.  Cerebral  ansemia.  Such  convulsions  are  seen  after  pro- 
fuse hemorrhage,  in  fatty  heart,  and  in  poisoning  from  cardiac 
paralyzants  like  aconite  and  veratrum  viride. 

Eclampsia.  This  term  is  applied  to  designate  accidental 
convulsions,  such  as  the  convulsions  of  childhood  resulting 
from  reflex  irritation,  and  the  convulsions  of  pregnancy  or- 
the  puerperium,  resulting  from  toxic  materials  retained  in  the 
blood. 

Tetanic  Convulsions. — In  this  form  the  discharges  emanate 
from  the  spinal  cord,  and  are  not  associated  with  a  loss  of  con- 
sciousness.    Tetanic  convulsions  may  result  from  : — 

1.  Tetanus.  This  is  recognized  by  the  history  of  a  wound, 
the  tonic  character  of  the  convulsions,  the  early  involvement 
of  the  jaw,  and  the  absence  of  fever. 

2.  Spinal  meningitis.  This  is  recognized  by  exquisite  pain 
in  the  back,  fever,  and  late  involvement  of  the  jaw. 

3.  Strychnia-poisoning.  This  is  recognized  by  the  history, 
the  intermittent  character  of  the  convulsions,  the  absence  of 
fever,  and  the  escape  of  the  muscles  of  the  jaw  until  very  late. 

4.  Tetany.  In  this  condition  the  extremities  are  chiefly  in- 
volved; the  convulsions  are  intermittent,  and  can  be  produced 
by  pressure  on  the  nerves  and  arteries  of  the  affected  limbs. 

Hysteroidal  Convulsions. — These  are  manifestations  of  hys- 
teria, and  in  them  consciousness  is  only  partially  or  apparently 
lost.     They  are  not  preceded  by  an  aura,  but  sometimes  by  a 


DISTUKBAJNCES   OF   MOTION.  333 

sensation  of  a  ball  in  the  throat — the  "globus  hystericus  ;"  the 
eyes  are  partially  closed ;  the  face  expresses  some  emotion ; 
the  tongue  is  not  bitten  ;  the  movements  are  tonic,  or  if  clonic, 
appear  wilful ;  the  paroxysm  is  of  long  duration ;  and  the 
patient  frequently  weeps  or  laughs. 

Local  Convulsions  or  Spasms. — Spasm  of  the  face  may  re- 
sult from  a  (1)  cortical  lesion  in  the  inferior  portion  of  the 
ascending  frontal  convolution ;  (2)  from  tic  convulsif — a  con- 
dition occurring  in  young  children,  affecting  the  facial  and 
neighboring  muscles,  and  associated  with  mimicry,  a  tendency 
to  use  profane  language,  and  various  mental  disturbances  ; 
(3)  from  habit  (habit  chorea) ;  and  sometimes  from  (4)  tic 
douloureux — neuralgia  of  the  fifth  nerve. 

Temporary  spasmus  of  one  arm  or  one  leg  are  usually  mani- 
festations of  Jacksonian  epilepsy  (focal  epilepsy),  but  they 
sometimes  result  from  hysteria. 

Spasm  of  the  hand  developing  lohen  the  member  is  put  to  use 
may  result  from  writers'  cramp,  Thomsen's  disease,  or 
hysteria. 

Spasm  of  the  cervical  muscles  (wry-neck,  torticollis)  may 
result  from  congenital  shortening  of  the  sterno-mastoid,  myal- 
gia, hysteria,  caries  of  the  vertebrae,  or  the  irritation  of  en- 
larged cervical  glands. 

Spasmus  of  the  larynx,  oesophagus,  and  diaphragm  (hiccough) 
have  already  been  discussed. 

Saltatory  Spasm. — This  term  is  employed  to  designate  a 
condition  allied  to  hysteria,  in  which  a  violent  spasm  seizes  the 
muscles  of  the  leg  as  soon  as  tlie  feet  touch  the  ground,  and 
as  a  result  the  patient  is  thrown  violently  into  the  air. 

Salaam  Convulsions These  consist  of  violent  paroxysmal 

bobbing  movements  of  the  head  or  trunk,  and  may  be  asso- 
ciated with  hysteria,  chorea,  or  rarely,  organic  brain  disease. 

Choreiform  Movements. 

These  are  coarse,  jerky,  irregular,  involuntary  movements 
which  more  or  less  simulate  purposive  movements.  They  may 
result  from  : — 

1.  Idiopathic  chorea  CSt.  Vitus's   dance).     This  disease  is 


334  DISEASES   OF   THE   NERVOUS  SYSTEM. 

seen  in  children  ;   is  usually  mild ;  runs  a  course  of  several 
weeks ;  and  is  prone  to  be  followed  by  endocarditis. 

2.  Chorea  insaniens.  A  grave  disease  occurring  in  adults, 
especially  pregnant  women,  and  characterized  by  violent  move- 
ments, delirium,  and  fever. 

3.  Huntingdon's  chorea  (chronic  chorea).  An  affection  oc- 
curring in  adult  life,  generally  hereditary,  and  characterized 
by  irregular  movements,  disturbance  of  speech,  and  increasing 
dementia. 

4.  Organic  brain  disease.  Choreiform  movements  are  fre- 
quently observed  in  cerebral  palsies  of  children ;  they  may 
also  develop  on  one  side  of  the  body  before  an  attack  of  apo- 
plexy (pre-hemiplegic  chorea),  or  in  the  paralyzed  members 
after  the  hemorrhage  (post-hemiplegic  chorea). 

5.  Peripheral  irritation.  Choreiform  movements  sometimes 
develop  in  pregnancy,  and  are  occasionally  noted  in  stumps 
after  amputation. 

6.  Habit.  Children  frequently  acquire,  through  constant 
repetition  or  mimicry,  choreiform  movements  which  may  last 
indefinitely. 

7.  Hysteria.  The  marked  rhythmical  character  of  the 
movements  and  the  history  will  aid  in  the  recognition  of 
hysterical  chorea. 

8.  Disseminated  cerebro-spinal  sclerosis.  This  disease  usu- 
ally induces  tremors,  but  not  uncommonly  the  movements  are 
choreiform.  The  increased  reflexes,  the  nystagmus,  the  loss 
of  power,  the  spastic  gait,  and  the  impairment  of  intellect 
will  aid  in  its  recognition. 

9.  Paramyoclonus  multiplex.  A  very  rare  disease,  of  un- 
known origin,  characterized  by  continued  or  paroxysmal 
choreiform  movements  which  develop  or  increase  under  ex- 
citement or  muscular  effort. 

Athetosis. 

This  term  was  employed  by  Hammond  to  designate  certain  • 
movements  occurring  chiefly  in  the  hands  and  feet,  and  charac- 
terized by  slow  twisting,  intertwining,  separation,  and  exten- 
sion of  the  fingers  and  toes.     Athetosis  is  frequently  observed 


DISTURBANCES   OF   MOTION.  335 

in  the  cerebral  palsies  of  children,  and  it  occasionally  occurs 
in  adults  as  a  result  of  lesions  in  the  basal  ganglia. 

Tremors. 

A  tremor  is  a  fine  vibratory  movement  due  to  the  alternate 
contraction  and  relaxation  of  antagonistic  muscles.  Tremors 
are  observed  in  the  following  conditions : — 

1.  They  may  exist  from  birth  unassociated  with  other 
symptoms. 

2.  They  may  depend  upon  a  lowered  tone  of  the  nervous 
system,  being  frequently  observed  in  neurasthenia  and  in  the 
convalescence  from  acute  disease. 

3.  They  may  be  toxic,  resulting  from  alcoholism  or  mer- 
curial poisoning. 

4.  They  may  be  due  to  old  age. 

5.  They  are  frequently  a  symptom  of  organic  disease  of  the 
brain  and  cord  ;  as  such,  they  are  met  with  in  paretic  dementia, 
and  especially  in  disseminated  sclerosis. 

6.  They  may  be  the  chief  symptom  in  paralysis  agitans. 

7.  They  may  be  hysterical. 

The  Gait. 

The  Ataxic  Gait, — In  locomotor  ataxia  the  patient  raises 
the  foot  high,  throws  it  forward^  and  brings  it  down  suddenly, 
so  that  the  whole  sole  comes  in  contact  with  the  floor  at  once. 

Spastic  Gait. — In  spastic  paraplegia  the  movements  are 
stiif,  the  knees  come  together,  the  leg  drags  behind,  and  the 
toe  catches  the  ground. 

Festination. — This  term  is  applied  to  the  gait  of  advanced 
paralysis  agitans ;  in  walking,  the  body  inclines  more  and 
more  forward,  and  the  steps  grow  faster  and  faster  until  the 
patient  falls,  straightens  himself  by  an  effort,  or  finds  support 
in  some  neighboring  object. 

Steppage  Gait. — In  chronic  multiple  neuritis  the  patient 
raises  the  foot  high,  turns  the  toe  up,  and  brings  the  heel  down 
first. 

The  Gait  of  Pseudo-muscular  Hypertrophy. — The  feet  are 
wide  apart,  the  belly  protrudes,  and  the  movements  are  clumsy 
and  waddling. 


336  DISEASES   OF   THE  NERVOUS  SYSTEM. 

Titubation. — This  term  is  applied  to  the  peculiar  gait  ob- 
served in  lesions  of  the  cerebellum.  It  resembles  the  gait  of 
locomotor  ataxia,  but  is  much  more  staggering.  It  is  not  de- 
pendent upon  loss  of  coordination,  for  in  lying  down  the 
patient  can  perfectly  control  his  movements.  The  absence  of 
the  Argyll-Robertson  pupil,  of  sharp  pains,  and  of  diminished 
reflexes  will  separate  cerebellar  disease  from  locomotor  ataxia. 

The  Reflexes. 

The  Knee-jerk,  or  Patellar  Tendon  Reflex. — This  is  ob- 
tained by  tapping  the  quadriceps  tendon  between  its  insertion 
and  the  patella  while  the  leg  is  crossed  over  its  fellow. 

The  knee-jerk  is  increased  in  the  following  conditions  : — 

1.  Frequently  in  organic  disease  of  the  brain,  probably  from 
irritation  of  the  cord. 

2.  In  incomplete  transverse  lesions  of  the  cord'  above  the 
lumbar  enlargement,  probably  from  cutting  off  the  influence 
of  the  reflex  inhibiting  centre  in  the  upper  part  of  the  cord. 

3.  In  disseminated  cerebro-spinal  sclerosis  and  in  lateral 
sclerosis. 

4.  In  irritability  of  the  cord,  as  in  mania,  hysteria,  strych- 
nia-poisoning, and  spinal  meningitis. 

The  knee-jerk  is  diminished  or  absent  in  the  following  con- 
ditions : — 

1.  Degeneration  of  the  muscle,  as  in  pseudo-muscular  hy- 
pertrophy. 

2.  In  lesions  of  the  nerves  which  cut  off"  the  impulse  from 
the  cord — as  neuritis. 

3.  In  lesion  of  the  posterior  columns  of  the  cord,  as  in  loco- 
motor ataxia. 

4.  In  poliomyelitis,  acute  and  chronic  (the  anterior  gray 
matter  is  part  of  the  reflex  centre). 

5.  In  advanced  myelitis,  when  the  cord  is  sufficiently 
injured. 

6.  In  exhaustion  of  the  spinal  centres,  as  after  prolonged 
laborious  work. 

7.  In  poisoning  from  drugs  which  depress  the  cord,  as  anti- 
mony, chloralj  etc. 


DISTURBANCES    OF    MOTION. 


337 


Ankle-clonus. — This  consists  of  vibratory  movements 
obtained  by  supporting  the  tencio- Achilles  with  one  hand,  while 
the  foot  is  strongly  flexed  with  the  other.  It  can  rarely  be 
obtained  in  health,  but  is  often  marked  in  hysteria  and  in 
lateral  sclerosis. 

Arm-jerk. — This  is  obtained  by  striking  the  biceps  tendon 
at  the  elbow,  or  the  triceps  tendon  above  the  olecranon. 

Jaw-jerk. — This  is  obtained  by  tapping  the  jaw  while  the 
mouth  is  partially  open. 

The  Superficial  Reflexes^ — These  are  probably  true  reflexes, 
and  consist  in  muscular  contractions  resulting  from  irritation 
of  the  skin. 

The  following  table  is  based  upon  the  description  given  by 
Ross  in  his  Handbook  of  Nervous  Diseases  : — 


The  Keflex. 
Plantar  .  .  . 

Gluteal  .  . 

Cremasteeic 

Abdominal    . 
Epigastric    .     . 

Erector  Spinal 

Scapular 

Palmar    .     .    .. 


Produced  by 

Tickling   the    sole   of    the 

foot. 
Stimulating  the  skin  over 

the  buttock. 
Stimulating   the    skin    on 

the    inner    side    of    the 

thigh. 
Stroking  the    skin  on   the 

side  of  the  abdomen. 
Stimulating    the    sides    of 

the  chest  in  the  fifth  and 

sixth  intercostal  spaces. 
Irritation    from   the  angle 

of  the    scapula    to    the 

iliac  crest. 
Irritation  of  the  scapular 

region. 


Tickling  the  palm. 


Depends  upon  Integrity  of 

The  lower  end  of  the  cord 
(conns  medullaris). 

Loops  through  the  fourth 
and  fifth  lumbar  nerves. 

First  and  second  pairs  of 
lumbar  nerves. 

The  arcs  from  the  eighth  to 

the  twelfth  dorsal  nerves. 
The    arcs   from   the  fourth 

to    the  seventh  pairs  of 

dorsal  nerves. 
The     arcs     in    the    dorsal 

region  of  the  cord. 

The  arcs  of  the  upper  two 
or  three  dorsal  and  the 
lower  two  or  three  cervi- 
cal nerves. 

The  arcs  through  the 
greater  part  of  the  cervi- 
cal enlargement. 


The  chief  cranial  reflexes  are  contraction  of  the  palatal 
muscles  by  irritation  of  the  fauces ;  sneezing,  by  irritation  of 
the  nares ;  cough,  by  irritation  of  the  larynx  ;  closure  of  the 
eyelids,  by  irritation  of  the  conjunctiva;  and  contraction  of 
the  iris,  by  light. 
22 


338  DISEASES   OP   THE   NERVOUS   SYSTEM. 

Paradoxical  Contraction.  (Westphal.) — Tliis  is  a  peculiar 
phenomenon  consisting  of  a  tetanic  contraction  of  the  tibialis 
anticus,  lasting  for  several  minutes,  and  induced  by  forcibly 
flexing  the  foot  on  the  leg.  Its  cause  is  unknown.  It  has 
been  observed  in  early  locomotor  ataxia,  multiple  sclerosis, 
hysteria,  and  j)aralysis  agitans. 

disturba:n^ces  of  sensatio:n^. 

These  consist  chiefly  in  a  loss  of  sensation — ancesthesia  ;  in- 
creased sensation — hypenesthesia  ;  certain  abnormal  sensations 
— parcesthesia  ;  and  subjective  painful  sensations — neuralgia. 

Ansestliesia. 

Ordinary  cutaneous  sensibility  may  be  tested  by  the  prick 
of  a  pin,  by  a  pinch,  or  by  the  faradic  current. 

Anaesthesia  results  from  interruption  of  the  sensory  tract  in 
the  nerves,  as  by  neuritis ;  from  interruption  of  the  sensory 
tract  in  the  cord  or  brain  ;  from  organic  disease  of  the  sensory 
area  of  the  brain ;  from  the  action  of  toxic  substances  on  the 
nerves  or  centres ;  from  certain  functional  conditions  like 
hysteria  ;  and  from  reflex  irritation. 

Hemiancesthesia. — A  loss  of  sensation  on  a  lateral  half  of 
the  body.     It  may  result  from  : — 

1.  Hysteria.  This  is  often  unassociated  with  paralysis  of 
motion,  and  may  be  recognized  by  the  history,  sex,  and  tem- 
perament of  the  patient ;  by  the  paroxysmal  character  of  the 
ausesthesia ;  and  by  exclusion  of  other  causes. 

2.  A  unilateral  lesion  high  in  the  cord.  This  is  very  rare, 
and  may  be  recognized  by  being  associated  with  hemiplegia  on 
the  opposite  side. 

3.  A  lesion  of  the  medulla  (very  rare).  The  hemianses- 
thesia  is  usually  associated  with  hemiplegia,  paralysis  of  the 
cranial  nerves,  difficult  swallowing,  and  cardiac  and  respiratory 
disturbances. 

4.  A  lesion  in  the  pons.  The  hemiansesthesia  is  often 
associated  with  hemiplegia  on  the  same  side,  and  facial  palsy 
on  the  opposite  side. 


DISTURBANCES    OF    SENSATION.  339 

5.  A  lesion  in  the  crns,  or  peduncle.  The  hemiansesthesia 
is  often  associated  with  hemiplegia  on  the  same  side  and 
paralysis  of  the  oculomotor  nerve  on  the  opposite  side. 

6.  A  lesion  of  the  posterior  limb  of  the  internal  capsule,  or 
of  the  optic  thalamus  pressing  on  the  capsule. 

7.  A  lesion  of  the  occipital  cortex. 

Monancesthesia. — A  loss  of  sensation  in  one  member.  It 
may  result  from  hysteria,  from  a  focal  lesion  of  the  occipital 
cortex,  or  from  a  lesion  of  the  nerves  supplying  the  member. 

Parancesthesia. — A  loss  of  sensation  in  all  parts  below  the 
waist.  It  may  result  from  hysteria,  organic  diseases  of  the 
cord,  neuritis  of  the  lower  extremities,  or  reflex  irritation. 

Thermo-ancesthesia.—lnsens'ih'ility  to  heat  or  cold  occurring 
as  an  independent  condition.  It  is  sometimes  observed  in 
hysteria  and  syringo-myelia. 

Analgesia. — Insensibility  to  pain.  It  is  sometimes  observed 
in  hysteria,  in  syringo-myelia,  and  in  lesions  of  the  spinal 
cord. 

Retardation  of  Sensations. — This  is  frequently  observed  in 
all  forms  of  anaesthesia,  but  especially  in  the  anaesthesia  of  loco- 
motor ataxia. 

The  Sense  of  Space. — The  distance  at  which  two  points 
of  contact  can  be  recognized  as  two  points.  Normally  the 
distance  varies  in  different  parts  and  in  different  individuals. 

On  the  cheek  it  is  11-15  millimeters. 

On  the  forehead,  22  millimeters. 

On  the  forearm,  40  millimeters. 

On  the  chest,  45  millimeters. 

On  the  thigh  and  upper  arm,  68  millimeters. 

On  the  leg,  40  millimeters. 

On  the  palm  of  the  hand,  8-12  millimeters. 

On  the  back  of  the  hand,  31  millimeters. 

Hypereesthesia  is  increased  sensibility  to  external  impres- 
sions. 

It  is  commonly  observed  in  hysteria,  especially  in  connection 
with  the  joints,  breasts,  genitalia,  and  spine.  It  is  also  ob- 
served in  neurasthenia,  and  in  beginning  inflammation  of  the 
nerves  and  of  the  cerebro-spinal  meninges. 


340  DISEASES    OF    THE    NERVOUS   SYSTEM. 

Paraesthesia. — This  term  is  used  to  indicate  certain  disa- 
greeable subjective  phenomena,  such  as  numbness,  tingling, 
itching,  creeping,  and  "  pins  and  needles." 

Par^esthesia  is  observed  in  many  conditions,  as  hysteria, 
spinal  sclerosis,  neurasthenia,  and  injury  or  inflammation  of 
the  nerves. 

Girdle  Sensation. — The  sense  of  having  a  girdle  or  tight  band 
around  the  trunk.     It  is  frequently  observed  in  spinal  sclerosis. 

Neuralgia, — This  consists  of  paroxysms  of  severe  pain 
radiating  along  the  line  of  the  nerve-trunks.  The  pain  is  re- 
lieved by  pressure,  but  there  are  tender  spots  {iioints  doulou- 
reux) where  the  nerve  makes  its  exit  from  bony  canals  or 
muscular  coverings. 

Lightning-pains. — This  term  is  applied  to  the  sharp  lancinat- 
ing pains  observed  in  locomotor  ataxia.  They  usually  occur 
in  the  extremities,  and  may  be  mistaken  for  rheumatism. 

Causalgia. — This  term  has  been  applied  by  S.  Weir  Mit- 
chell to  an  intensely  burning  sensation  generally  observed  in 
"glossy  skin." 

Pressure  Sense. — By  this  sense  the  amount  of  pressure 
exerted  on  a  given  part  of  the  body  is  determined.  It  may 
be  tested  by  placing  upon  the  palms  or  fingers  objects  of  the 
same  bulk  but  of  different  weight,  the  hands  being  supported 
upon  a  table. 

Muscular  Sense. — This  is  the  sense  by  which  weight,  mus- 
cular eift)rt,  and  position  are  determined.  It  is  often  defective 
in  hysteria,  locomotor  ataxia,  and  in  many  forms  of  paralysis. 


disturba:n^ces  of  intjtritio:^. 

These  consist  in  atrophy  of  the  muscles,  changes  in  electro- 
muscular  contractility,  tissue-metamorphoses,  and  in  certair 
abnormalities  of  the  appendages. 


I 


DISTUEBANCES   OF   NUTRITION.  341 

Muscular  Atrophy. 

Atrophy,  or  wasting  of  the  muscles  results  from : — 

1.  Inactivity.  Cerebral  palsies  may  thus  be  associated  with 
slow  wasting. 

2.  Lesions  of  the  cells  in  the  anterior  gray  horns  of  the 
cord,  as  in  acute  and  chronic  poliomyelitis. 

3.  Lesions  of  the  nerves,  such  as  neuritis  or  traumatism. 

4.  Certain  diseases  of  the  muscles  themselves,  as  idiopathic 
muscular  atrophy. 

The  atrophy  which  attends  chronic  affections  of  the  joints 
probably  results  from  neuritis. 

The  Reaction  of  Degeneration. 

In  muscular  paralysis  there  may  be  simply  diminished  elec- 
trical excitability.  This  is  termed  a  quantitative  change.  In 
some  cases,  however,  there  is  a  complete  reversal  of  the  normal 
phenomena.  This  is  termed  a  qualitative  change,  or  the  I'eaction 
of  degeneration. 

The  reactions  of  degeneration  are  obtained  with  the  galvanic 
current  applied  to  muscles  in  the  advanced  stage  of  degeneration. 

The  subjoined  table,  setting  forth  the  electro-muscular 
phenomena  in  health  and  disease,  follows  closely  the  description 
ofH.  C.Wood  :— 

The  anode — the  positive  pole  ;  the  cathode — the  negative 
pole.  When  a  galvanic  current  of  moderate  strength  is  em- 
ployed, and  the  cathode  is  placed  over  the  normal  muscle,  a 
strong  contraction  occurs  when  the  circuit  is  closed ;  when  the 
anode  is  placed  over  the  muscle  the  contraction  is  much  less  ; 
in  neither  case  is  there  any  contraction  when  the  current  is 
broken.  When  a  strong  current  is  used  contractions  are  pro- 
duced, and  the  anodal  contraction  is  greater  than  the  cathodal. 
The  reaction  of  degeneration  consists  in  a  reversal  of  these 
phenomena. 


342  DISEASES  or  the  nervous  system. 


Normal  muscle. 

A  nodal  closing  contraction  (AnClC)  is  less  than  the  catho- 
dal closing  contraction  (CaClC). 

Auodal  opening  contraction  (AnOC)  is  greater  than  the 
cathodal  opening  contraction  (CaOC). 

Muscle  in  first  stage  of  degeneration. 

Anodal  closing  contraction  (AnClC)  equals  the  cathodal 
closing  contraction  (CaClC). 

Anodal  opening  contraction  (AnOC)  equals  the  cathodal 
opening  contraction  (CaOC). 

Iluscle  in  advanced  stage  of  degeneration, 

Anodal  closing  contraction  (AnClC)  is  greater  than  the 
cathodal  closing  contraction  (CaClC). 

Anodal  opening  contraction  (AnOC)  is  less  than  the  cathodal 
opening  contraction  (CaOC). 

The  reactions  of  degeneration  are  observed  in  diseases  which 
destroy  the  trophic  cells  in  the  anterior  gray  horns  of  the  cord 
or  which  cut  off  their  influence.  Thus  they  are  observed  in 
acute  and  advanced  chronic  poliomyelitis,  in  acute  central  mye- 
litiSj  in  severe  neuritis,  and  after  section  or  compression  of  the 
nerves. 


Arthropathies. 

An  arthropathy  is  a  degenerative  affection  of  the  joints, 
characterized  by  marked  swelling  due  to  effusion,  erosion  of 
the  cartilages,  relaxation  and  calcification  of  the  ligaments,  and 
atrophy  of  the  heads  of  the  bones.  Arthropathies  are  observed 
especially  in  locomotor  ataxia,  syringo-myelia,  and  in  cerebral 
hemiplegia.  Some  regard  the  joint-phenomena  of  rheumatoid 
arthritis  as  belonging  to  this  class. 


DISTURBANCES   OF   CONSCIOUSNESS.  843 

Ulceration  Resulting  from  Perverted 
Nutrition. 

Acute  Decubitus. — This  term  is  api)liecl  to  ulcers  appearing 
in  a  few  hours  or  days,  on  parts  subjected  to  pressure,  after  the 
occurrence  of  a  severe  cerebral  or  spinal  lesion. 

Chronic  Decubitus. — This  term  is  applied  to  the  ulcers  which 
ultimately  appear  on  parts  subjected  to  pressure  in  the  course 
of  chronic  spinal  affections. 

Perforating  Ulcer  of  the  Foot. — This  term  is  applied  to  an 
undermining  ulcer  of  the  foot  most  commonly  observed  in 
locomotor  ataxia.  It  frequently  penetrates  the  deep  structures 
and  involves  the  bones. 

Symmetrical  Gangrene  {Raynaud's  Disease). — This  is  a  gan- 
grenous affection  involving  the  fingers,  toes,  tip  of  the  nose, 
or  ears.  It  arises  spontaneously,  and  is  probably  due  to  a 
vaso-motor  spasm. 

Trophic  Affections  of  the  Skin.  —  Herpes,  scleroderma, 
vitiligo,  chloasma,  and  the  "glossy  skin"  following  injuries 
of  the  nerve-trunks,  are  illustrations  of  this  class  of  trophic 
phenomena. 

Trophic  Affections  of  the  Hair  and  Nails. — After  injury  of 
the  nerves  and  in  neuritis  the  nails  often  become  dry,  brittle, 
and  cracked.  Under  similar  conditions  there  may  be  a  loss  of 
hair,  an  overgrowth  of  hair,  or  a  change  in  the  color  of  the 
hair. 

DISTURBANCES  OF  CONSCIOUSNESS. 

Coma. 

Coma  is  a  condition  of  unconsciousness  from  which  the 
patient  cannot  be  aroused. 

Temporary  unconsciousness,  due  to  anaemia  of  the  brain, 
is  termed  syncope,  which  may  be  recognized  by  the  extreme 
pallor,  weak  pulse,  and  feeble  heart-sounds. 

1.  Coma  may  result  from  traumatism.  This  can  only  be 
recognized  by  the  history  or  the  local  evidence  of  injury. 

2.  Organic  Disease  of  the  Brain. — The  most  common  cause 
under  this  head  is  apoplexy,  which  may  be  recognized  by  the 
history,  the  age,  the  condition  of  the  arteries,  and  by  evidences 


344  DISEASES   OF   THE   NERVOUS    SYSTEM. 

of  paralysis,  such  as  unnatural  relaxation  or  rigidity  on  one 
side  of  the  body,  conjugate  deviation  of  the  eyes,  or  a  higher 
temperature  in  one  axilla. 

3.  Epilepsy. — The  coma  of  epilepsy  is  usually  of  short  dura- 
tion. It  may  be  recognized  by  the  history,  by  the  bloody 
saliva,  by  the  presence  of  scars  on  the  tongue  from  previous 
attacks,  and  by  the  exclusion  of  other  causes. 

4.  Thermic  Fever  (Sunstroke). — The  temperature  of  the  day 
or  of  the  room  in  which  the  patient  is  fouud,  the  extremely 
high  body-temperature,  and  the  absence  of  other  causes  will 
usually  prevent  an  error' in  diagnosis. 

5.  Certain  Drugs. — Under  this  head  come  alcoholism  and 
opium-poisoning.  In  alcoholism  the  patient  can  generally  be 
aroused  by  shouting  in  the  ear,  there  is  the  odor  on  the  breath, 
and  there  is  an  absence  of  other  cause. 

In  opium-poisoning  the  pupils  are  small,  the  respirations 
are  slow,  the  temperature  is  normal  or  subnormal ;  there 
may  be  the  odor  of  laudanum  on  the  breath.  The  diagnosis 
will  be  aided  by  the  exclusion  of  other  causes. 

6.  Uroemia. — In  this  condition  there  is  a  urinous  odor  to 
the  breath ;  the  aortic  second  sound  is  accentuated;  the  urine 
is  scanty  and  contains  albumin ;  the  temperature  may  be 
above  or  below  normal;  the  pupils,  are  usually  small,  and 
there  is  no  evidence  of  other  cause. 

7.  The  Infectious  Fevers. — The  history  is  sufficient  to  make 
the  diagnosis.  Pernicious  malarial  fever  may  produce  sudden 
coma,  and  in  this  condition  the  examination  of  the  blood 
would  render  a  diagnosis  possible. 

8.  Hysteria. — The  history,  age,  and  sex  of  the  patient,  and 
the  absence  of,  other  cause  will  suggest  the  condition. 

9.  AceioncEmia. — Diabetic  coma  may  be  recognized  by  the 
history,  the  sweetish  odor  of  the  breath,  the  glycosuria,  and 
the  subnormal  temperature. 

Trance. 

In  this  condition  the  patient  lies  for  several  days  apparently 
dead,  the  pulse  and  respiration  being  imperceptible.  It  is 
usually  a  manifestation  of  hysteria. 


DISTUEBANCES    OF   THE   SPECIAL   SENSES.  345 

Somnambvilism. 

A  dreamlike  state,  in  which  the  patient  performs  aujo- 
matically  various  feats — such  as  walking,  singing,  writing,  etc. 
Mild  forms,  such  as  talking  and  walking  in  sleep,  may  occur 
in  health.  More  marked  manifestations  occur  in  hysteria  and 
in  hypnotism. 

Ecstasy. 

A  condition  of  apparent  insensibility  in  which  the  mind  is 
wholly  absorbed  with  a  fancy  or  delusion.  It  occurs  in  the 
hysterical.  The  dancing  mania  of  the  middle  ages  is  a  good 
illustration  of  it. 

Catalepsy. 

This  term  is  applied  to  attacks  characterized  by  a  peculiar 
stiffness  of  the  muscles,  and  when  this  is  overcome  by  force 
the  limbs  can  be  placed  in  unnatural  positions,  which  they 
retain  for  a  long  time.  There  may  or  may  not  be  a  loss  of 
consciousness  and  sensation.  It  is  observed  in  hysteria,  hyp- 
notism, in  some  cases  of  epilepsy,  in  some  organic  diseases  of 
the  brain,  and  in  certain  forms  of  insanity — notably  katatonia. 

DISTURBANCES  OF  THE  SPECIAL  SENSES. 

The  Eye. 

llyosis. — Contraction  of  the  pupil  occurs  in  many  condi- 
tions, notably  in  locomotor  ataxia,  paretic  dementia,  some 
cases  of  disseminated  sclerosis,  meningitis,  cerebral  tumor, 
old. age,  uraemia,  and  opium-poisoning. 

Mydriasis. — Dilatation  of  the  pupil  is  also  observed  in 
many  conditions,  notably  in  atrophy  of  the  optic  nerve, 
paralysis  of  the  third  nerve,  collapse,  severe  pain,  epileptic 
seizures,  hysterical  attacks,  belladonna-poisoning,  and  in  some 
cases  of  locomotor  ataxia  and  paretic  dementia. 

Inequality  of  the  Pupils, — This  may  occur  in  health,  in 
ocular  defects,  in  organic  brain  disease,  in  paretic  dementia, 
in  locomotor  ataxia,  in  aneurism  pressing  on  the  cervical  sym- 
pathetic, and  in  unilateral  paralysis  of  the  oculo-motor  nerve. 


346  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Argyll-Robertson  Pupil. — This  is  one  which  fails  to  respond 
to  light,  but  still  accommodates  for  distance.  It  is  noted  espe- 
cially in  locomotor  ataxia  and  paretic  dementia. 

Conjugate  Deviation  of  the  Eyes. — This  term  is  applied  to 
the  rotation  of  both  eyes  away  from  the  median  line.  It  is 
noted  especially  in  apoplexy  and  in  convulsions  of  organic 
brain  disease. 

Nystagmus  {Tremor  of  the  Eyehall.)  —  It  may  be  con- 
genital, associated  with  certain  ocular  troubles,  or  due  to 
disease  of  basal  ganglia.  It  is  especially  frequent  in  dissem- 
inated sclerosis  and  Friedreich's  ataxia. 

Optie  Neuritis,  or  PajnUitis. — An  inflammatory  aifection 
of  the  intraocular  end  of  the  optic  nerve.  The  term  "  choked- 
disk  "  is  used  to  designate  the  condition  when  it  is  accom- 
panied with  marked  swelling.  Its  chief  causes  are  :  Tumor 
of  the  brain,  cerebral  meningitis,  syphilis,  toxic  agents  (lead 
and  alcohol),  infectious  fevers,  anaemia,  and  Bright's  disease. 

Atrophy  of  the  Optic  Nerve. — As  a  primary  affection  it  is 
most  commonly  observed  in  locomotor  ataxia  and  paretic 
dementia.  Secondary  atrophy  results  from  pressure  of  tu- 
mors, aneurisms,  etc.,  on  the  optic  chiasm.  Consecutive 
atrophy  is  a  sequel  of  optic  neuritis. 

The  Ear. 

Tinnitus  Aurium  [Noises  in  the  Ear). — They  are  observed 
in  cerebral  hypersemia  and  anaemia,  in  diseases  of  the  ear,  in 
Meniere's  disease,  and  after  the  use  of  certain  drugs  like 
quinine  and  salicylic  acid.  -■ 

Hyperacusis  of  Hearing. — This  is  sometimes  observed  in 
hysteria,  in  facial  paralysis,  and  in  cerebral  hypersemia. 

Deafness  generally  depends  upon  disease  of  the  ear  itself. 

PSYCHICAL  DISTURBANCES. 

Delusion. — A  delusion  is  a  faulty  belief  concerning  a  subject 
capable  of  physical  demonstration,  out  of  which  the  person 
cannot  be  reasoned  by  adequate  methods  for  the  time  being. 
(Wood.) 


PSYCHICAL    DISTURBANCES.  347 

A  systematized  delusion  is  one  which  the  patient  endeavors 
:o  defend  by  a  process  of  reasoning  more  or  less  logical.  Sys- 
tematized delusions  are  especially  observed  in  monomania. 

An  unsystematized  delusion  is  one  which  the  patient  makes 
Qo  attempt  to  justify  ;  he  asserts  his  belief  without  reason. 
The  majority  of  delusions  are  unsystematized ;  and  as  such  are 
observed  in  most  fornis  of  insanity. 

A  fixed  delusion  is  one  which  the  patient  retains  for  a  con- 
siderable length  of  time  ;  it  is  frequently  systematized.  Fixed 
delusions  are  observed  in  monomania,  paretic  dementia,  hys- 
terical insanity,  and  sometimes  in  melancholia. 

An  expansive  delusion,  or  a  delusion  of  grandeur,  is  one 
which  exalts  its  possessor.  The  patient  conceives  that  he  is 
some  noted  personage,  that  he  is  worth  millions  of  dollars,  or 
that  he  is  capable  of  performing  certain  marvellous  feats.  Ex- 
pansive delusions  are  frequently  observed  in  paretic  dementia, 
mania,  and  hysterical  insanity. 

A  hypochondriacal  delusion  is  one  which  depresses  its 
possessor.  The  patient  believes  that  he  has  committed  the 
unpardonable  sin,  that  he  is  being  persecuted,  or  that  he  is 
the  victim  of  some  dread  disease.  Hypochondriacal  delusions 
are  frequently  observed  in  melancholia,  alcoholic  insanity,  and 
in  some  cases  of  monomania  and  paretic  dementia. 

Illusion. — An  illusion  is  a  perverted  perception.  Thus  in 
delirium  tremens  the  patient  may  transform  every  piece  of 
furniture  into  a  demon  or  reptile. 

Hallucination.  —  An  hallucination  is  a  false  perception, 
entirely  subjective,  and  not  based  upon  any  knowledge  derived 
from  without.  An  individual  who  hears  voices  and  sees  ob- 
jects when  none  exist  is  the  subject  of  hallucinations. 

Imperative  Conception. — A  conception  which  the  person 
knows  to  be  false,  but  which,  nevertheless,  dominates  his 
thoughts  and  often  directs  his  actions.  When  he  fails  to 
recognize  the  falsity  of  his  conception,  it  becomes  a  delusion. 
A  morbid  impulse  is  an  irresistible  desire  to  commit  an  act 
which 'the  patient  knows  to  be  wrong.  It  is  usually  the  result 
of  an  imperative  conception. 

Kleptomania  is  a  morbid  desire  to  steal.     Pyroinania  is  a 
morbid  desire  to  set  fire  to  buildings. 


348  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Delirium. 

Delirium  is  a  mental  state  characterized  by  a  rapid  flight  of 
ideas  which  are  incoherent  and  often  unintelligible.  It  may 
result  from  : — 

Acute  Delmwm  {BelVs  Mania). — A  disease  arising  without 
obvious  cause,  and  characterized  by  an  abrupt  onset,  active 
delirium,  a  constant  repetition  of  certain  phrases  or  acts, 
moderate  fever,  often  a  bullous  eruption,  and  exhaustion.  It 
generally  ends  fatally  in  the  course  of  a  few  weeks. 

Mania. — In  this  affection  the  onset  is  not  abrupt.  Symp- 
toms of  impaired  health  and  mental  depression,  covering  a 
period  of  sevei^al  weeks  or  months,  generally  precede  the  out- 
break of  the  delirium. 

Hysteria. — The  history,  age,  sex,  and  temperament,  and  the 
intermittent  character  of  the  delirium  will  aid  in  the  diagnosis. 

One  of  the  Infectious  Fevers. — Pneumonia  and  typhoid  fever 
are  especially  liable  to  be  associated  with  delirium.  The 
physical  signs  in  the  former  and  the  abdominal  symptoms  in 
the  latter  will  usually  indicate  the  diagnosis. 

Urcemia.^— The  urinous  odor  of  the  breath,  the  high  arterial 
tension,  the  accentuation  of  the  second  aortic  sound,  and  the 
presence  of  albumin  and  casts  in  the  urine  will  suggest  uraemia. 

Alcoholis^n. — The  history,  the  appearance  of  the  patient,  the 
marked  tremors,  and  frequently  terrifying  hallucinations  will 
indicate  alcoholism. 

Inanition. — A  form  of  delirium  occasionally  arises  in  the 
course  of  exhausting  diseases.  It  is  associated  with  pallor, 
feeble  pulse,  and  cold  extremities.  It  is  generally  of  short 
duration,  and  may  be  recognized  by  the  circumstances  under 
which  it  develops. 


TUBERCULAR   MENINGITIS.  'i-lB 

TUBERCULOUS  ]\IE:M]yGITIS. 

(Basilar  Meningitis,  Acute  Hydrocephalus.) 

Definition. — An  acute  inflammation  of  the  cerebral  men- 
inges excited  by  the  tubercle  bacillus. 

Etiology. — In  children  the  disease  mav  be  primary,  but 
in  adults  it  is  always  secondary  to  a  primary  focus  of  tuber- 
culosis in  some  other  part  of  the  body.  The  majority  of  cases 
are  observed  between  the  second  and  the  fifth  years.  Heredity, 
bad  hygienic  surroundings,  and  poor  food  (milk  from  a  tuber- 
culous mother)  are  predisposing  factors. 

Pathology, — The  basilar  meninges  are  especially  involved. 
The  pons,  crura,  and  medulla  are  covered  wnth  soft  lymph 
which  mats  together  in  a  common  mass  the  adjacent  nerves 
and  bloodvessels.  The  tuberculous  character  of  the  inflam- 
mation is  manifested  by  the  presence  of  small  yellowish 
nodules  which  are  particularly  abundant  along  the  bloodvessels 
in  the  Sylvian  fissures.  The  amount  of  fluid  in  the  ventricles 
is  increased,  and  the  ependyma  is  soft  and  oedematous.  The 
cortical  substance  underlying  the  aflFected  meninges  is  also 
soft  and  infiltrated  with  leucocytes. 

Symptoms. — The  disease  usually  begins  insidiously  with 
certain  prodromal  symptoms.  The  disposition  of  the  child 
changes  ;  he  ceases  to  play  ;  he  becomes  dull  and  listless,  and 
when  disturbed,  irritable.  Sleep  is  broken  and  fitful ;  the 
child  twitches,  grinds  his  teeth,  or  starts  up  with  a  cry  of 
alarm.  Headache  develops,  and  is  soon  associated  with  fever 
and  vomiting ;  the  tongue  is  coated  ;  the  appetite  lost ;  and 
the  bowels  constij^ated.  When  the  disease  is  fully  developed 
the  headache  becomes  intense,  and  freq  uently  causes  from  time 
to  time  a  shrill  scream — the  "hydrocephalic  cry."  The 
special  senses  are  abnormally  acute,  so  that  bright  lights  and 
loud  sounds  cannot  be  tolerated.  The  surface  is  also  hyperses- 
thetic,  and  when  touched,  the  child  becomes  extremely 
irritable.  The  temperature  is  moderately  high  (102°-103°)  ; 
the  pulse  is  at  first  rapid,  but  later  slow  and  irregular ;  the 
abdominal  walls  are  retracted  ;  the  muscles  of  the  neck  rigid ; 
and  the   pupils  contracted.     Convulsive  seizures   frequently 


350  DISEASES   OF   THE   NERVOUS   SYSTEHf. 

develop ;  they  may  be  general  or  local.  The  child  lies  on 
one  side  with  tlie  limbs  drawn  up,  the  head  strongly  retracted, 
and  the  fingers  clinched  over  the  thumb,  which  is  turned 
into  the  palm.  Towards  the  close  of  this  stage  delirium 
develops. 

When  the  exudate  is  sufficient  in  amount  to  exert  marked 
pressure,  paralytic  phenomena  develop.  Local  palsies,  espe- 
cially of  the  facial  muscles,  take  the  place  of  convulsions ; 
coma  follows  delirium  ;  the  pupils  dilate  and  the  eyes  roll  up ; 
photophobia  is  replaced  by  blindness,  and  intolerance  of 
sound  by  deafness.  If  the  finger  is  drawn  across  the  body, 
a  bright  red  line  develops  and  lingers  for  some  minutes;  this 
is  the  tdcM  cerebrale  of  Trousseau.  The  pulse  now  becomes 
rapid  and  irregular ;  the  respiration  assumes  the  Cheyne- 
Stokes  type,  and  the  temperature  falls.  The  duration  is  from 
one  to  three  weeks. 

Diagnosis.  Typhoid  Fever. — Typhoid  fever  may  closely 
simulate  meningitis,  especially  in  the  young ;  but  the  early 
development  of  cerebral  symptoms,  the  irregular  fever,  the 
slow  pulse  of  the  first  stage,  the  retracted  abdominal  walls, 
the  constipation,  and  the  absence  of  rose-colored  spots  will 
serve  to  distinguish  meningitis  from  typhoid  fever. 

Simple  3Ieningitis. — An  absolute  diagnosis  may  be  impos- 
sible, but  the  history  of  tuberculosis  in  the  family,  the  presence 
of  tuberculous  foci  in  other  parts,  the  detection  of  tubercle  on 
the  retina,  and  an  onset  without  obvious  cause  will  generally 
indicate  the  true  nature  of  the  case. 

Peognosis. — Absol utely  unfavorable. 

Treatment. — The  patient  should  be  placed  in  a  quiet, 
dark,  well- ventilated  room.  The  diet  should  be  liquid.  An 
ice-bag  should  be  applied  to  the  head.  Constipation  should 
be  relieved  by  enemata.  For  the  headache,  restlessness,  and 
convulsions,  chloral  and  bromide  of  potassium  are  useful,  and 
may  be  given  by  the  rectum. 

^   Moschi,  gr.  iij  ; 
Camphoree,  gr.  xv ; 
Chloral,  hydrat.,  gr.  viiss  ; 
Yitelli  ovl,  No.  i ; 
Aq.  destillat.,  fgiv.— M.     (Simon.) 
Sig. — Wash  out  the  rectum  with  a  simple  enema  and  inject  two 
ounces. 


CHEONIC   PACHYMENI]SrGITIS.  351 

The  administration  of  ergot  and  of  iodide  of  potassium,  and 
the  external  application  of  an  ointment  of  iodoform  to  the 
shaved  scalp    have  been  recommended,  but  generally  prove 

useless. 

SIMPLE  LEPT03IE]SriNGITIS. 

(Acute  Leptomeningitis,  Meningitis  of  the  Convexity.) 

Definition. — An  acute  inflammation  of  the  pia  mater 
not  due  to  tubercle. 

Etiology. — Traumatism,  sunstroke,  rheumatism,  Bright's 
disease,  and  the  infectious  fevers,  are  the  usual  predisposing 
causes.  It  occasionally  develops  from  caries  of  the  bone  which 
is  secondary  to  middle-ear  disease. 

Pathology. — The  membranes  are  opaque,  thickened,  con- 
gested, adherent,  and  more  or  less  infiltrated  with  purulent 
fluid.  Generally  the  convexity  is  affected,  but  in  some  cases, 
as  those  following  middle-ear  disease,  the  base  is  chiefly  in- 
volved. The  adjacent  cortical  substance  is  also  oedematous, 
soft,  and  injected. 

Symptoms. — Moderate  irregular  fever,  loss  of  appetite,  con- 
stipation, intense  headache,  intolerance  to  light  and  sound, 
contracted  pupils,  delirium,  retraction  of  the  head,  convulsions, 
and  coma. 

When  the  base  is  involved,  the  symptoms  are  almost  identi- 
cal with  those  of  tuberculous  meningitis. 

Peognosis. — Unfavorable,  though  recovery  is  not  im- 
possible. 

Treatment. — The  patient  should  be  placed  in  a  quiet, 
dark,  well-ventilated  room.  An  ice-bag  should  be  applied  to 
the  head.  When  the  patient  is  robust,  wet  cups  or  leeches  may 
be  applied  to  the  neck.  The  diet  must  be  liquid.  Constipa- 
tion should  be  relieved  by  enemata.  Restlessness,  headache, 
and  convulsions  call  for  chloral  and  bromide  of  potassium. 

CHRONIC  LEPTOMENINGITIS. 

Definition. — A  chronic  inflammation  of  the  pia  mater. 
Etiology. — It  may  result  from  syphilis,  alcoholism,  trau- 
matism, or  sunstroke.     It  may  be  secondary  to  acute  infec, 


352  DISEASES    OF    THE    NERVOUS   SYSTEM. 

tious  leptomeningitis.  It  is  an  associated  condition  in  abscess 
and  tumors  of  the  brain. 

Symptoms. — Persistent,  dull  headache,  mental  deteriora- 
tion, vertigo,  muscular  weakness,  a  low  grade  of  optic  neu- 
ritis, and  occasionally  nausea,  vomiting,  and  tinnitus.  Acute 
exacerbations  are  not  infrequent,  and  are  characterized  by 
fever,  severe  headache,  delirium,  convulsions,  and  stupor. 

Diagnosis.  Cerebral  Tumor. — In  tumor  the  symptoms 
are  more  severe  and  of  a  more  focal  character,  and  the  optic 
neuritis  is  of  a  high  grade. 

Urcemia. — This  condition  may  be  recognized  by  the  albu- 
minuric retinitis  and  the  presence  of  albumin  and  casts  in 
the  urine. 

Prognosis. — More  or  less  unfavorable.  A  cure  is  some- 
times obtained  in  cases  resulting  from  syphilis,  sunstroke, 
and  traumatism. 

Treatment. — In  syphilitic  meningitis  mercury  and  po- 
tassium iodide  should  be  used  freely.  In  other  ' instances 
courses  of  ergot  and  potassium  bromide  are  useful.  Applica- 
tions of  the  thermo-cautery  often  give  relief.  Tonics  and 
hypnotics  are  frequently  indicated. 

CHRONIC  PACHYMENINGITIS. 

Definition. — Inflammation  of  the  dura  mater. 

Etiology. — Inflammation  of  the  external  layer  may  result 
from  injury,  syphilis,  sunstroke,  or  caries  of  the  bone.  In- 
flammation of  the  internal  layer  (hemorrhagic  pachymeningitis) 
may  be  secondary  to  chronic  cardiac  or  renal  disease,  one  of 
the  infectious  fevers,  chronic  alcoholism,  or  especially,  insanity. 

Hemorrhagic  Pachymeuiugltis. 

(Haematoma  of  the  Dura  Mater.) 

Pathology. — The  membranes  are  thickened,  opaque,  and 
more  or  less  adherent.  The  bloodvessels  are  dilated.  Be- 
tween the  membranous  layers  are  frequently  observed  hemor- 
rhagic effusions  ;  these  vary  in  extent  from  slight  ecchymoses 
to  clots  as  large  as  a  hen's  egg.    In  some  cases  the  pressure  of 


HYDROCEPHALUS.  353 

the  clots  on  the  convolutions  is  sufficient  to  cause  the  latter  to 
atrophy. 

Symptoms. — Often  ohscure.  In  some  cases  there  are  no 
manifestations  during  life.  When  the  condition  is  marked, 
the  following  phenomena  may  be  observed  :  Headache,  failure 
of  memory,  impairment  of  intellect,  stupor,  contracted  pupils, 
local  convulsions,  or  palsies.  The  symptoms  may  alternately 
improve  and  grow  worse  for  a  long  period.  In  grave  cases, 
associated  with  extensive  hemorrhagic  effusion,  the  symptoms 
resemble  apoplexy. 

Diagnosis. — This  can  rarely  be  made  with  certainty. 

Prognosis. — Unfavorable. 

Treatment. — Grave  cases  should  be  treated  as  apoplexy. 

HYDROCEPHALUS. 

(Congenital  Hydrocephalus,  Water  on  the  Brain.) 

Definition. — A  condition  in  which  there  is  an  excessive 
accumulation  of  fluid  in  the  ventricles  or  arachnoid  cavity. 

Etiology. — Acquired  Hydrocephalus  may  develop  at  any 
period  of  life,  and  may  result  from  meningitis,  the  pressure  of 
a  tumor,  or  from  one  of  the  causes  of  general  dropsy. 

Congenital  Hydrocephalus,  the  forra  now  under  discussion, 
dates  from  birth  or  develops  in  the  first  few  years  of  life.  Its 
cause  is  unknown ;  in  some  cases  it  is  probably  due  to  a  latent 
inflammation  of  the  ependyma  of  the  ventricles. 

Pathology. — The  head  is  large  and  round ;  the  bones  are 
thin  and  translucent ;  the  sutures  and  fontanelles  are  enlarged, 
and,  if  life  has  been  prolonged,  are  filled  with  numerous 
Wormian  bones.  The  convolutions  of  the  brain  are  flattened 
and  the  sulci  more  or  less  obliterated.  In  external  hydro- 
cephalus the  accumulation  of  fluid  is  found  in  the  arachnoid  sac; 
but  in  internal  hydrocephalus — the  more  common  form — the 
ventricles  are  greatly  distended  with  a  watery  fluid  of  low 
specific  gravity,  containing  a  trace  of  albumin.  The  epen- 
dyma is  often  thickened  and  roughened.  Malformations  are 
frequently  observed,  and  probably  result  from  the  same  cause 
which  induced  the  effusion. 
23 


354  DISEASES    OF   THE    NERVOUS   SYSTEM. 

Symptoms. — Sometimes  the  disease  develops  before  birtn. 
and  the  large  head  interferes  with  the  delivery  of  the  child. 
In  other  cases  nothing  peculiar  is  observed  until  the  child  if. 
several  months  old,  when  the  swelling  of  the  head  attracts 
the  attention  of  the  parents.  The  head  assumes  a  globular 
shape';  the  fontanelles  and  sutures  remain  open ;  the  face  be- 
comes relatively  small ;  the  eyes  protrude  and  are  directed 
downward  from  the  pressure  of  the  fluid  on  the  supraorbital 
plates ;  the  scalp  appears  thin  and  stretched ;  the  superficial 
veins  are  distended ;  and  the  hair  becomes  scant.  In  some 
cases  the  head  is  so  heavy  that  the  thin  neck  can  no  longer 
support  it,  and  it  falls  forward  on  the  breast. 

As  a  rule,  the  intelligence  is  considerably  impaired,  but  ex- 
ceptional cases  are  marked  by  precociousness.  Motor  phe- 
nomena are  frequently  present :  the  reflexes  are  exaggerated ; 
one  or  more  of  the  members  may  be  the  seat  of  a  spastic 
paralysis ;  convulsions  develop  in  many  cases. 

The  duration  varies  in  different  cases.  The  large  majority 
soon  die  of  inanition,  convulsions,  or  some  intercurrent  disease 
to  which  their  reduced  vitality  makes  them  an  easy  prey ;  but 
in  a  few,  life  is  prolonged  for  many  years. 

Diagnosis. — Hydrocephalus  must  not  be  mistaken  for 
rachitic  enlargement  of  the  head.  In  the  latter,  the  head  is 
square  instead  of  globular;  the  intelligence  is  good;  there  are 
no  motor  phenomena ;  and  bony  enlargements  are  usually 
detected  at  the  ends  of  the  long  bones  and  at  the  junction  of 
the  cartilages  with  the  ribs. 

Prognosis. — Unfavorable.  In  a  few  cases  arrest  of  the 
disease  has  been  spontaneous,  or  has  resulted  from  aspiration 
of  the  fluid. 

Treatment. — The  treatment  is  unsatisfactory.  Counter- 
irritation  and  the  use  of  diuretics  and  absorbents  exert  no 
influence  on  the  disease.  In  the  majority  of  cases,  beyond 
dietetic  and  hygienic  measures  and  the  occasional  use  of  tonics, 
little  can  be  recommended.  In  cases  where  the  pressure- 
symptoms  are  marked,  tapping  offers  some  hopes  of  tem- 
porary relief.  After  the  operation  compression  of  the  skull 
should  be  made  by  the  application  of  concentric  bands  of 
adhesive  plaster. 


PARETIC    DEMENTIA.  355 


PARETIC  DE3IEXTIA. 

(General  Paralysis  of  the  Insane,  General  Paresis,  Chronic 
Meningo-encephalitis.) 

Defixitiox. — A  chronic  inflammatory  affection  of  the 
cerebral  cortex,  characterized  by  a  change  of  disposition, 
faihire  of  memory,  mental  exaltation,  delusions  of  grandeur, 
tremors,  epileptiform  seizures,  and  paralysis. 

Etiology. — Male  sex,  middle  life,  prolonged  mental  strain, 
and  excesses  are  predisposing  factors.  It  may  be  induced  by 
the  usual  causes  of  sclerosis,  namely,  syphilis,  alcoholism,  lead- 
poisoning,  gout,  etc. 

Pathology. — The  membranes  are  opaque,  thickened,  and 
at  places,  adherent  to  the  brain  substance.  The  cortex  is  more 
or  less  atrophied  and  increased  in  firmness.  Microscopic 
examination  reveals  an  overgrowth  of  connective  tissue  and 
degeneration  of  nerve-fibres  and  ganglionic  cells. 

In  some  cases  similar  degenerative  changes  are  observed  in 
the  posterior  and  lateral  columns  of  the  cord. 

Symptoms. — The  disease  usually  begins  insidiously  with  a 
change  in  disposition  ;  the  industrious  become  slothful ;  the 
ambitious,  apathetic;  the  chaste,  dissolute;  the  liberal,  parsi- 
monious ;  the  complaisant,  churlish  ;  and  the  truthful,  false. 
The  energy  relaxes,  the  judgment  weakens,  and  the  memory 
fails.  As  the  facuhies  become  impaired,  a  peculiar  egotism 
and  a  mental  exaltation  develop ;  the  patient  becomes  boastful, 
loquacious,  and  easily  provoked  to  furious  outbreaks.  The 
failure  of  memory  is  early  noted  in  writing,  by  the  use  of 
wrong  letters  and  the  suppression  of  syllables.  At  this  time 
motor  j)henomena  may  be  observed  :  the  tongue  trembles  when 
it  is  protruded  ;  the  speech  is  slow,  hesitating,  and  indistinct ; 
the  pupils  are  often  unequal ;  and  the  gait  is  somewhat 
shuflQing. 

The  most  characteristic  psychical  symptom  of  fully-de- 
veloped paretic  dementia  is  the  delusion  of  grandeur :  the 
patient  conceives  that  he  is  some  distinguished  personage,  that 
he  owns  acres  of  land,  or  that  he  is  the  inventor  of  some 
wonderful  machine.     The  mind  is  usually  serene  and  cheerful, 


35(j  DISEASES   OF    THE    NERVOUS   SYSTEM. 

but  periods  of  depression  are  not  infrequent.  The  sensibilities 
are  blunted  and  the  animal  nature  emphasized.  The  mind 
becomes  more  and  more  involved  ;  there  is  extreme  indifference 
to  all  that  transpires ;  the  appetite  is  voracious,  and  in  eating 
the  patient  bolts  his  food  and  soils  his  clothes.  The  tremor 
of  the  tongue  increases,  and  spreads  to  the  lips  and  other  parts 
of  the  face;  the  speech  is  indistinct  and  "scanning  ;"  the  puj)ils 
fail  to  respond  to  light,  but  still  accommodate  for  distance 
(Argyll-Robertson  pupil) ;  the  reflexes  are  generally  increased. 
Spellsofunconscionsnessresemblingprf?7m«Z  are  not  uncommon. 

In  the  final  stage  mental  power  is  almost  obliterated  ;  the 
health  fails ;  the  bladder  and  rectum  become  unretentive  ;  the 
gait  is  more  unsteady ;  and  at  last  the  patient  is  unable  to 
leave  his  bed.  Death  usually  results  from  exhaustion  or  in- 
tercurrent disease. 

Diagnosis. — The  insidious  change  in  disposition,  failure  of 
memory,  tremors,  Argyll-Robertson  pupil,  and  delusions  of 
grandeur  are  the  diagnostic  features. 

Cerebral  Syphilis. — In  this  disease  the  history,  the  occur- 
rence of  convulsions  and  of  partial  facial  palsies,  the  absence 
of  delusions  of  grandeur  and  of  "  scanning"  speech,  and  the 
eifect  of  treatment  will  usually  prevent  an  error  in  diagnosis. 

Prognosis. — Unfavorable.  The  course  is  not  uniform  ;  in 
some  cases  there  are  remissions,  or  lucid  intervals,  which  last 
several  months  or  years.  The  average  duration  is  three  or 
four  years. 

Treatment. — Rest  of  body  and  mind.  Careful  attention 
to  the  hygiene.  When  there  is  a  suspicion  of  syphilis,  iodides 
and  mercurials  should  be  given  a  thorough  trial.  As  a  rule, 
patients  must  be  removed  to  asylums.  • 

CEREBRAL  PABALYSIS  IN  CHILDREN. 

Definition.  —  Hemiplegia,  diplegia,  or  paraplegia  ap- 
pearing at  birth  or  in  the  first  few  years  of  life,  and  usually 
associated  with  atrophy  and  sclerosis  of  the  cerebral  cortex, 
or  porencephalus. 

Pathology. — After  death  one  of  the  following  conditions 
is  observed  :  Atrophy  and  sclerosis  of  the  convolutions  ;  poren- 


CEREBEAL    HYPER.EMIA.  357 

oephalus  (a  cystic  condition  of  the  cortex)  ;  or  more  rarely, 
some  local  obstruction  to  the  cerebral  circulation,  as  from 
hemorrhage,  embolism,  or  thrombosis.  The  exciting  cause  of 
the  porencephalus  and  sclerosis  is  still  undetermined. 

Symptoms. — In  the  hemipleg'w  v^ariety  the  onset  is  sudden, 
and  is  frequently  attended  with  fever,  convulsions,  or  coma. 
After  a  few  hours  or  davs  these  severe  symptoms  subside,  and 
the  child  is  left  paralyzed  on  one  side  of  the  body.  In  rare 
instances  the  paralysis  ultimately  disappears  and  the  child  is 
restored  to  health,  but  in  the  large  majority  of  cases  it  persists 
and  is  followed  by  secondary  rigidity.  Imbecility,  epilepsy, 
and  choreiform  or  athetoid  movements  in  the  affected  members 
are  very  common  sequelae. 

The  diplegie  or  paraplegic  form  frequently  dates  from  birth, 
and  is  characterized  by  rigidity  and  loss  of  power  in  all  of  the 
extremities.  The  legs  suffer  more  than  the  arms.  Chorei- 
form or  athetoid  movements  are  frequently  present.  Children 
thus  affected  are  generally  idiots  or  imbeciles.  Meningeal 
hemorrhage,  induced  by  tedious  labor  or  the  use  of  the  for- 
ceps, appears  to  be  responsible  for  this  variety. 

Treatment. — During  the  convulsive  stage  an  ice-bag 
should  be  applied  to  the  head,  and  chloral  or  bromide  admin- 
istered by  the  mouth  or  rectum.  The  paralysis  resists  treat- 
ment ;  but  subsequent  rigidity  may  be  lessened  by  massage 
and  passive  movements,  and  the  deformity  by  mechanical 
appliances.^ 

CEREBRAL  HYPER^3IIA. 

(Congestion  of  the  Brain.) 

Etiology. — Acute  congestion  results  from  exposure  to  the 
sun  ;  from  the  use  of  certain  drugs,  like  alcohol  and  nitro- 
glycerine; from  excesssive  brain-work;  or  from  some  reflex 
disturbance,  as  gastric  irritation. 

Chronic  congestion  results  from  some  local  obstruction   to 

the  return  of  blood  from  the  brain,  as  by  a  tumor  in  the  neck ; 

from  obstruction  to  the  general  circulation,  as  in  chronic  heart 

and  lung  disease ;  from  the  suppression  of  some  habitual  dis- 

'  The  above  description  is  based  upon  Osier's  elaborate  monograph. 


358  DISEASES   OF    THE    NERVOUS    SYSTEM. 

charge,  as  the  menstrual  flow  at  the  menopause  ;  or  from  some 
general  cause,  such  as  prolonged  anxiety,  overwork,  excesses, 
irregular  living,  etc. 

Pathology. — The  vessels  of  the  meninges  and  of  the 
brain-substance  are  engorged. 

Symptoms.  Acute  Form. — Intense  headache ;  vertigo  ; 
intolerance  to  light  and  sound  ;  restlessness  ;  tinnitus  aurium  ■ 
and  sleeplessness,  or  sleep  disturbed  by  horrible  dreams. 

Chronic  Form. — Vertigo;  dull  headache;  failure  of 
memory;  irritability;  inability  to  concentrate  the  thoughts; 
and  disturbed  sleep.  The  symptoms  grow  worse  when  the  re- 
cumbent posture  is  assumed.  Ophthalmoscopic  examination 
reveals  retinal  hypersemia.  In  marked  cases  there  may  be 
exacerbations  closely  resembling  a|3oplexy,  in  which  there  is 
unconsciousness,  followed  by  temporary  paresis. 

Progxosis. — Depends  on  the  cause ;  when  this  can  be 
removed  the  prognosis  is  favorable. 

Treatment.  Acute  Congestion. — The  patient  should  be 
placed  in  a  darkened,  well -ventilated  room.  The  head  and 
shoulders  should  be  slightly  elevated.  An  ice-bag  should  be 
applied  to  the  head.  Leeches  or  wet-cups  may  be  applied  to 
the  neck.  Sedatives  like  bromide  of  potassium  and  aconite 
are  useful.  Ergot  may  be  employed  for  its  power  to  contract 
the  vessels.  If  there  is  constipation,  it  should  be  relieved  by  a 
brisk  saline  purge. 

In  chronic  cases  the  cause  should  be  ascertained  and,  if 
possible,  removed.  The  habits  of  the  patient  must  be  regu- 
lated. The  diet  must  be  light  and  nutritious.  Constipation 
must  be  relieved  by  diet  or  by  the  occasional  use  of  a  saline 
laxative.  Sedatives  like  bromide  of  potassium  and  aconite  are 
useful.     In  the  apoplectiform  attacks  venesection  is  indicated. 

CEREBRAL  A^^^MIA. 

Etiology^. — General  cerebral  anaemia  as  a  chronic  affection 
may  result  from  cardiac  disease,  especially  aortic  stenosis.  It 
may  be  associated  with  general  anaemia.  It  may  be  due  to 
atheromatous  obstruction  of  the  arteries. 


CEREBRAL    HEMORRHAGE.  359 

Overwork,  prolonged  emotional  excitement,  irregular  living, 
and  excesses  are  also  said  to  predispose. 

As  an  acute  condition  it  exists  in  syncope  and  shock  ;  after 
hemorrhage ;  after  the  sudden  withdrawal  of  fluid  from  the 
abdominal  sac ;  and  after  ligation  of  the  carotid  artery. 

Symptoms.  Acute  Form. — Pallor  of  the  face,  vertigo, 
confusion  of  ideas,  ringing  in  the  ears,  dimness  of  vision,  dila- 
tation of  the  pupil,  nausea,  and  a  tendency  to  yawn.  In 
extreme  aneemia  there  may  be  convulsions  and  coma. 

The  chronic  form\s  characterized  by  vertigo,  headache,  dis- 
turbed sleep,  intolerance  to  light  and  sound,  irritability  of 
temper,  failure  of  memory,  inability  to  concentrate  the  atten- 
tion on  one  subject,  a  tendency  to  syncope,  and  extreme  lassi- 
tude. The  symptoms  improve  when  the  patient  lies  down. 
Ophthalmoscopic  examination  reveals  pallor  of  the  retina. 

Diagnosis. — Cerebral  ansemia  closely  simulates  cerebral 
congestion,  but  in  the  latter  there  is  no  tendency  to  syncope ; 
the  symptoms  grow  worse  when  the  patient  lies  down  ;  the 
ophthalmoscope  reveals  retinal  hypersemia ;  the  pupils  are 
contracted  instead  of  dilated,  and  the  urine  is  apt  to  be  de- 
creased. 

Prognosis. — Depends  on  the  cause ;  when  this  can  be  re- 
moved the  prognosis  is  favorable. 

Treatment. — In  acute  cases  diffusible  stimulants  like 
nitro-glycerin,  ammonia,  and  strychnia  are  indicated.  In 
chronic  cases  the  cause  should  be  ascertained,  and  if  possible, 
removed.  When  it  is  due  to  general  anaemia,  iron,  arsenic, 
and  quinine  are  useful  remedies.  When  dependent  on  valvu- 
lar disease,  rest  and  the  use  of  digitalis,  strophanthus,  or 
strychnine  are  the  remedial  measures. 


CEREBRAL  HEMORRHAGE. 

(Cerebral   Apoplexy.) 

Etiology. — The  affection  is  most  commonly  met  with  in 
the  old,  in  whom  the  bloodvessels  are  atheromatous,  and  in 
the  very  young,  in  whom  they  are  naturally  weak.  All 
causes   which   lead  to  degeneration   of  the  arteries^   such   as 


360  DISEASES   OF   THE    NERVOUS    SYSTEM. 

rheumatism,  gout,  syphilis,  alcoholism,  and  Bright's  disease, 
predispose  to  it.  Suiferers  from  chronic  Bright's  disease  are 
very  liable  to  die  of  apoplexy  on  account  of  the  association  of 
cardiac  hypertrophy  with  arterial  degeneration.  Heredity- 
predisposes,  inasmuch  as  members  of  certain  families  are 
particularly  prone  to  sclerosis  of  the  vessels.  The  attack 
may  be  precipitated  by  mental  or  physical  excitement,  alco- 
holic excess,  or  some  reflex  disturbance,  as  gastric  irritation. 
In  children  it  may  be  excited  by  a  paroxysm  of  whooping- 
cough  or  by  a  convulsion. 

Pathology. — In  children  the  hemorrhage  is  most  com- 
monly cortical;  in  adults  it  is  usually  within  the  brain-mass. 
The  bloodvessels  are  generally  atheromatous,  and  are  some- 
times the  seat  of  miliar}-  aneurisms.  The  clot  varies  greatly 
in  size;  sometimes  it  is  small,  merely  a  capillary  oozing;  at 
other  times  it  may  fill  a  hemisphere.  Its  most  common  seat 
is  the  internal  capsule — the  motor  highway  between  the  optic 
thalamus  and  the  corpus  striatum.  In  recent  hemorrhages 
the  clot  is  dark  and  soft,  and  the  surrounding  tissue  stained 
and  more  or  less  lacerated.  If  the  hemorrhage  has  not  been 
very  copious,  the  clot  loses  it  color,  shrinks,  and  is  finally 
absorbed,  and  the  damaged  cerebral  fibres  are  replaced  by 
proliferated  connective  tissue,  which  contracts  and  forms  a 
scar  more  or  less  pigmented  with  h?ematoidin.  In  other  cases, 
instead  of  a  scar,  a  cyst  is  formed  which  encloses  a  clear  straw- 
colored  fluid.  Large  effusions  in  the  motor  path  may  produce 
secondary  changes — either  a  softening  of  the  cerebral  tissue 
beyond,  or  a  degeneration  which  travels  down  the  lateral 
column  of  the  cord  on  the  side  opposite  the  lesion. 

Symptoms. — Prodromal  symptoms  indicating  cerebral  con- 
gestion frequently  precede  the  attack ;  these  are  headache, 
vertigo,  disturbed  sleep,  tinnitus  aurium ;  or  there  is  a  sense 
of  numbness  or  weakness  on  the  side  which  is  to  be  affected. 
Persistent  vomiting  sometimes  precedes  the  hemorrhage. 

The  Attach. — In  many  cases  the  patient  falls  suddenly  un- 
conscious without  previous  warning.  The  face  is  flushed; 
the  eyes  are  injected  ;  the  lips  are  blue;  the  breathing  is  ster- 
torous ;  the  pulse  is  full  and  slow  ;  the  temperature  is  at  first 
subnormal  from  shock,  but  later  it  is  elevated  from  irritation ; 


CEREBRAL    HEMORRHAGE.  361 

and  the  urine  and  feces  may  be  passed  involuntarily.  Convul- 
sive seizures  are  not  infrequent;  they  result  from  irritation 
transmitted  to  the  undamaged  motor  regions.  Even  while  the 
patient  is  comatose  the  paralysis  can  be  detected.  The  head 
and  eyes  may  be  strongly  rotated  to  one  side  (conjugate  devia- 
tion) ;  one  cheek  often  flaps  more  than  the  other ;  the  pupils 
may  be  irregular;  any  movements  which  the  patient  may 
make  are  restricted  to  the  sound  side ;  when  the  affected  arm 
is  raised  and  let  fall,  it  drops  lifeless  or  manifests  an  unnatural 
rigidity ;  and  occasionally  there  is  a  difference  of  temperature 
in  the  two  axillae.  In  grave  cases  the  patieiit  does  not  awake 
from  the  coma ;  the  pulse  grows  feeble ;  the  respirations  assume 
the  Cheyne-Stokes  type ;  the  reflexes  are  abolished ;  mucus  col- 
lects in  the  throat  and  produces  a  rattling  sound  ;  the  tempera- 
ture rises  high  ;  and  death  results  after  the  lapse  of  a  few  hours 
or  one  or  two  days. 

In  some  cases  the  paralysis  develops  quite  gradually  and  is 
not  attended  with  unconsciousness. 

Subsequent  Symptoms.  —  When  the  attack  does  not  prove 
fatal,  consciousness  is  finally  restored,  and  if  the  hemorrhage 
is  in  its  usual  location,  there  remains  a  hemiplegia  on  the 
opposite  side.  In  a  few  hours  the  affected  muscles  become 
rigid  from  irritation  of  the  motor  fibres.  This  early  rigidity 
is  termed  primary  rigidity ;  it  lasts  from  a  few  days  to  several 
weeks  and  has  no  significance  from  a  prognostic  standpoint.  The 
paralysis  is  rarely  a  complete  hemiplegia  ;  the  muscles  of  the 
upper  part  of  the  face  and  thorax  usually  escape,  because  they 
are  accustomed  to  act  in  unison  with  their  fellows  on  the  op- 
posite side,  and  such  muscles  are  rarely  involved  in  cerebral 
hemiplegia.  When  the  tongue  is  protruded,  it  deviates  toward 
the  paralyzed  side.  The  deep  reflexes  are  exaggerated  on 
the  affected  side.  Sensation  is  unimpaired  unless  the  pos- 
terior limb  of  the  internal  capsule  is  also  involved,  when  there 
is  hemiansesthesia  with  hemiplegia.  The  gait  is  peculiar ;  in 
walking  the  patient  supports  the  paralyzed  arm,  and  swings 
the  leg  forward  by  a  rotary  movement  imparted  to  it  by  the 
trunk.  When  the  clot  has  been  small,  the  paralysis  may 
completely  disappear.  More  frequently  recovery  is  only  par- 
tial ;  the  power   of   the   facial    muscles   is   usually  restored 


362  DISEASES    OF    THE    NERVOUS   SYSTEM. 

entirely,  and  the  leg  improves  more  than  the  arm.  In  unfavor- 
able cases  the  muscles  again  become  rigid  (secondary  rigidity) 
from  a  degenerative  process  travelling  down  the  lateral  column 
of  the  cord;  this  condition  is  indicative  of  permanent  dis- 
ability. Generally  the  mental  power  remains  unimijaired, 
but  sometimes  the  symptoms  of  cerebral  softening  gradually 
develop. 

Diagnosis. — The  coma  of  apoplexy  must  be  distinguished 
from  unemia,  opium-poisoning,  alcoholism,  and  sunstroke.  The 
age  of  the  patient ;  the  condition  of  the  arteries  ;  the  evidence 
of  paralysis  ;  the  difference  of  temperature  in  the  two  axillae ; 
and  the  absence  of  other  cause  will  usually  prevent  an  error  in 
diagnosis. 

Embolism. — This  usually  occurs  in  earlier  life;  it  is  com- 
monly associated  with  valvular  disease ;  premonitory  symp- 
toms are  rarely  present ;  the  pulse  is  more  often  weak  than 
strong ;  disturbances  of  temperature  and  breathing  are  less 
marked. 

Thrombosis. — This  also  produces  hemiplegia,  but  its  de- 
velopment is  very  gradual ;  unconsciousness  is  often  absent, 
and  temperature  and  breathing  are  not  much  disturbed. 

Hemiplegia  from  other  Causes. — Tumors  and  abscess  in  the 
brain  may  produce  hemiplegia,  but  the  latter  develops  gradu- 
ally and  is  usually  associated  with  other  cerebral  phenomena, 
such  as  persistent  headache,  vertigo,  ocular  palsies,  choked 
disk,  etc. 

Hysterical  Hemiplegia. — In  hysteria  the  face  escapes  ;  there 
is  frequently  anaesthesia  on  the  affected  side  ;  the  gait  is  pecu- 
liar, in  that  the  patient  pushes  the  paralyzed  limb  instead  of 
swinging  it.  These  features  together  with  the  age,  tempera- 
ment, sex,  and  mode  of  onset  will  usually  suggest  the  true 
cause. 

Prognosis. — Always  doubtful.  Persistent  and  complete 
unconsciousness,  high  temperature,  loss  of  reflexes,  and  embar- 
rassed respiration  are  unfavorable  phenomena.  When  the  at- 
tack does  not  prove  fatal,  there  is  always  a  probability  of 
subsequent  ones,  for  the  etiological  conditions  still  remain. 

Treatment.  Prophylaxis. — Patients  predisposed  to  apo- 
plexy should  lead  a  quiet  life,  free  from  mental  and  physical 


OBSTRUCTION    OF    THE    CEREBRAL    ARTERIES.  363 

excitemeut.  The  diet  slioakl  be  nutritious,  but  easily  diges- 
tible. Constipation  should  be  relieved  by  the  occasional  use  of 
a  saline  laxative.  To  secure  a  free  return  of  the  blood  from, 
the  brain  the  clothes  at  the  neck  should  be  loose. 

The  Attack. — The  head  and  slioulders  should  be  slightly 
elevated,  and  an  ice-bag  applied  to  the  head.  Croton  oil 
(gtt.  j-iij)  in  a  little  glycerine  or  olive  oil  may  be  j)laced  on 
the  back  of  the  tongue  to  secure  prompt  catharsis.  If  the 
pulse  is  strong,  venesection  is  indicated  and  should  be  con- 
tinued until  the  pulse  softens.  Bleeding  cannot  undo  the 
damage  already  done,  but  by  relieving  cerebral  congestion  it 
may  prevent  a  renewed  outpouring.  On  the  other  hand,  when 
the  face  is  pale  and  the  pulse  feeble  the  hypodermic  injection 
of  diffusible  stimulants,  like  ammonia  and  strychnia,  is  indi- 
cated. When  collections  of  mucus  interfere  with  breathing,  the 
patient  should  be  gently  turned  on  his  side  and  the  mucus 
removed. 

To  prevent  the  formation  of  bedsores  the  position  should 
be  frequently  changed,  and  the  parts  subjected  to  pressure 
thoroughly  cleansed. 

Subsequent  Treatment. — As  other  attacks  are  liable  to  occur, 
the  prophylactic  treatment  already  referred  to  is  applicable 
here.  Iodide  of  potassium  (gr.  v-x  thrice  daily)  may  be  ad- 
ministered with  the  ho|)e  of  absorbing  the  clot.  After  the 
lapse  of  six  or  eight  weeks,  faradism,  massage,  and  passive 
movements  should  be  applied  to  the  affected  muscles.  Strych- 
nine by  the  mouth  or  injected  directly  into  the  muscles  is 
often  very  useful.  Even  when  the  paralysis  remains,  con- 
tractures may  be  prevented  to  a  considerable  extent  by 
massage. 

OBSTRUCTION  OF  THE  CEREBRAIi  ARTERIES. 

(Embolism,  Throm.bosis.) 

Etiology.  —  Cerebral  emboli  may  be  derived  from  the 
valves  of  the  heart  in  endocarditis ;  from  an  atheromatous  plate 
in  the  aorta ;  or  from  a  clot  in  the  heart  or  in  the  sac  of  an 
aneurism.      Obstruction  from   embolism  may  occur  at   any 


364  DISEASES   OF   THE    NERVOUS   SYSTEM. 

age,  but  it  is  far  more  commonly  observed  in  young  adults 
than  at  the  extremes  of  life. 

Thrombi  are  clots  formed  in  the  vessels,  and  a  weak  heart 
and  arterial  degeneration  are  the  predisposing  factors.  They 
are  usually  observed  in  advanced  years,  but  those  dependent 
on  syphilitic  arteritis  frequently  occur  in  early  adult  or  middle 
life.' 

Pathology. —  Emboli  are  most  frequently  found  in  a 
branch  of  the  left  middle  cerebral  artery.  When  the  artery 
obstructed  is  a  large  one,  the  part  beyond  usually  becomes 
pale  and  soft;  but  sometimes  it  presents  the  appearance  of 
an  infarction  and  is  infiltrated  with  blood.  Subsequently, 
microscopic  examination  reveals  fatty  degeneration  of  the 
nervous  elements  and  more  or  less  pigmentation  from  extra- 
vasated  blood.  If  the  area  affected  is  small,  absorption  may 
follow  and  scar-tissue  be  substituted. 

Thrombi  are  usually  fonnd  in  the  middle  cerebral,  basilar, 
or  vertebral  arteries,  and  are  followed  by  similar  changes.. 

Symptoms. — An  embolus  lodging  in  the  middle  cerebral 
artery  usually  causes  abrupt  hemiplegia,  and  frequently 
aphasia.  There  may  be  no  prodromes,  and  consciousness 
may  be  preserved  during  the  seizure. 

When  the  basilar  artery  is  obstructed,  there  may  be  exten- 
sive paralysis  on  both  sides  of  the  body,  and  later,  symptoms 
of  bulbar  disease,  namely,  paralysis  of  the  lips,  pharynx, 
and  oesophagus,  disturbance  of  tlie  heart,  and  Cheyne-Stokes 
breathing. 

In  thrombosis  the  symptoms  are  similar  to  embolism,  but  they 
develop  very  slowly,  and  are  frequently  preceded  by  prodromes 
indicating  disturbed  cerebral  circulation,  such  as  headache, 
vertigo,  disturbed  sleep,  failure  of  memory,  numbness  and 
tingling  in  the  limbs  to  be  affected, 

Subsequent  Symptoms. — In  both  embolism  and  thrombosis, 
if  the  artery  obstructed  has  been  large,  the  paralysis  persists 
and  symptoms  of  cerebral  softening  appear — namely,  failure 
of  memory,  vertigo,  headache,  disturbed  sleep,  great  irrita- 
bility, and  finally  dementia. 

Diagnosis. — Cerebral  embolism  closelv  resembles  apoplexy, 


CEREBRAL    SOFTENING.  365 

and  sometimes  it  may  be  impossible  to  distinguish  between  the 
two  conditions.     The  following  are  the  diagnostic  features  : — ■ 

Embolism  is  generally  associated  with  valvular  disease ;  it 
commonly  occurs  in  the  young ;  prodromes  are  frequently  ab- 
sent;  aphasia  is  more  common  in  embolism  than  in  hemor- 
rhage ;  there  is  much  less  disturbance  of  temperature  after 
embolism  than  after  apoplexy ;  consciousness  is  less  apt  to  be 
lost  in  embolism  than  in  apoplexy. 

Prognosis. — In  embolism  it  is  very  doubtful ;  recovery 
may  follow,  but  often  the  paralysis  remains.  In  thrombosis 
there  is  very  little  liope  of  recovery,  unless  the  cause  is  syphilis. 

Treatment. — After  obstruction  from  embolism  the  patient 
should  be  kept  at  absolute  rest  for  a  few  days,  and  subsequently 
the  paralysis  treated  as  after  apoplexy.  In  thrombosis  treat- 
ment is  of  no  avail,  save  in  syphilitic  subjects,  when  mercurial 
inunctions  should  be  employed  freely  and  the  bichloride  given 
by  the  mouth. 

CEREBRAL  SOFTEIVIIVG. 

Definition. — Degeneration  of  the  brain-subsiance  resulting- 
from  impaired  nutrition. 

Etiology. — Local  softening  may  result  from  obstruction 
to  the  circulation  by  a  tumor,  embolism,  thrombosis,  or  clot. 
Extensive  softening  may  result  from  prolonged  cerebral  ansemia 
or  congestion.  It  is  most  frequently  observed  in  old  people  in 
association  with  atheromatous  arteries. 

Pathology. — The  affected  portion  is  dull  white  or  reddish- 
yellow,  according  to  the  amount  of  blood-pigment  present; 
and  is  less  firm  than  the  surrounding  brain-substauce.  Some- 
times it  is  so  soft  that  when  the  brain  is  cut  a  creamy  fluid 
flows  out.  Microscopic  examination  reveals  destruction  of  the 
nerve-elements  and  their  substitution  by  granular  debris  and 
fat-drops. 

Symptoms. — When  extensive  the  symptoms  are :  Failure 
of  memory,  irritability  of  temper,  vertigo,  headache,  partial 
palsies,  cutaneous  anaesthesia  or  parsesthesia,  delusions,  and 
finally  dementia. 

Local  softening  may  be  manifested  by  local  paralysis. 


366  DISEASES    OF    THE    NERVOUS    SYSTEM, 

Diagnosis.  Cerebral  Tumor. — Tumors  usually  develop  in 
younger  subjects ;  the  headache  is  more  severe ;  choked  disk 
is  frequently  observed. 

Prognosis. — Unfavorable. 

Treatment. — Palliative. 

MOKBID  GROWTHS  IN  THE  BRATN. 

(Tumors  of  the  Brain.) 

Etiology. — Early  adult  life,  male  sex,  and  perliaps  trau- 
matism predispose.  Heredity  also  predisposes  to  the  extent 
that  it  favors  the  development  of  cancer,  gumma,  and  tubercle. 

Varieties. — Tubercle,  gumma,  glioma,  aneurism,  cysts, 
sarcoma,  and  carcinoma  are  the  most  common  varieties. 
Less  frequently  fibroma,  psammoma,  and  lipoma  are  ob- 
served. 

,  Pathology. — Tuberculous  tumors,  or  tyromata,  vary  in  size 
from  a  pea  to  an  egg ;  they  may  be  single  or  multiple ;  and 
are  usually  observed  in  the  young. 

Gumma. — This  appears  as  a  round,  yellow,  caseous  mass, 
and  is  nearly  always  on  the  surface  of  the  brain,  into  which  it 
grows  from  the  overlying  membranes.  It  is  usually  met  with 
between  thirty  and  forty. 

Glioma. — This  tumor  is  found  almost  exclusively  in  the 
brain.  It  arises  from  the  neuroglia,  and  may  be  soft  like 
brain-substance  or  firm  like  fibrous  tissue.  It  is  chiefly  met 
with  in  the  young. 

Aneurism. — Encephalic  aneurism  may  be  single  or  mul- 
tiple. Miliary  aneurisms  of  small  vessels  frequently  excite 
apoplexy.  The  most  common  seats  of  large  aneurisms  are 
the  middle  cerebral,  basilar,  and  internal  carotid  arteries. 

Cysts. — These  are  usually  congenital  (porencephalus),  or 
result  from  hemorrhage,  but  sometimes  they  result  from  the 
taenia  echinococcus  (hydatid  cyst),  or  taenia  solium  (cysticercus 
cellulosae). 

Sarcoma. — This  is  usually  a  circumscribed  tumor,  and 
commonly  grows  from  the  membranes,  periosteum,  or  bone. 

Carcinoma. — This  is  nearly  always  secondary  and  multiple. 

Symptoms. — (1)  Headache   is   rarely  absent;   it  may  be 


MORBID    GROWTHS    IN    THE    BRAIN.  367 

localized  and  associated  with  tenderness  on  pressure.  (2) 
Vomiting  is  a  common  symptom,  especially  in  tumors  of  the 
base  of  the  brain  ;  it  is  often  unassociated  with  nausea  and 
does  not  relieve  the  attending  headache.  (3)  Ocular  phe- 
nomena, as  optic  neuritis,  or  choked  disk,  optic  atrophy,  diplo- 
pia, hemianopia,  blindness,  and  irregular  pupils,  (4)  Vertigo. 
(5)  Psychical  phenomena,  as  failure  of  memory,  irritability 
of  temper,  depression  of  spirits,  and  dementia.  (6)  Symp- 
toms resulting  from  local  pressure,  such  as  local  palsies  or 
convulsions,  aphasia,  and  local  anaesthesia. 

Diagnosis. — This  includes :  (1)  the  existence  of  a  tumor, 
(2)  its  character,  and  (3)  its  location. 

The  existence  of  a  tumor  is  determined  by  the  headache, 
vomiting,  optic  neuritis,  and  symptoms  of  local  pressiu'e. 

Abscess. — Cerebral  tumor  must  be  distinguished  from 
abscess.  The  latter  usually  results  from  traumatism  or  is 
secondary  to  a  focus  of  suppuration  in  some  other  part  of  the 
body ;  its  progress  is  more  rapid ;  choked  disk  is  rare ;  and 
there  is  often  febrile  disturbance. 

Chronic  Meningitis. — In  this  aifection  the  symptoms  indi- 
cate a  diffuse  lesion;  disturbances  of  temper,  memory,  and  sleep 
are  more  marked ;  and  optic  neuritis  is  not  frequent. 

The  Character  of  the  Growth. — This  cannot  always  be  deter- 
mined. The  early  age,  the  rapid  progress,  and  the  family 
history  may  suggest  tubercle.  The  early  age,  slow  progress, 
and  mild  pressure-symptoms  may  suggest  glioma.  The  his- 
tory, age,  and  concomitant  symptoms  will  indicate  syphilis. 
The  presence  of  a  primary  growth  will  lead  to  the  diagnosis 
of  cancer.  The  presence  of  a  thrill,  bruit,  and  marked  tinni- 
tus, and  the  absence  of  optic  ujpuritis  would  suggest  aneurism. 

Location. — The  following  facts  relating  to  cerebral  localiza- 
tion will  aid  in  determining  the  location  of  the  growth. 

Motor  area.  This  consists  of  the  ascending  frontal  and 
ascending  parietal  convolutions,  and  the  paracentral  lobule 
which  lies  along  the  median  fissure.  When  the  tumor  irritates 
the  part,  convulsion  results ;  when  it  exerts  enough  jjressure 
to  destroy  function,  paralysis  results. 

Central  portion  of  the  motor  area — spasm  or  paralysis  of  one 
arm. 


368  DISEASES    OF    THE    XEEVOUS   SYSTEM. 

Tlie  lotver  portion  of  the  motor  area — spasm  or  paralysis  of 
one  side  of  the  face. 

Paracentral  lohule — spasm  or  paralysis  of  a  lower  ex- 
tremity. 

Posterior  part  of  the  third  frontal  convolution  {left  side) — 
motor  or  ataxic  aphasia. 

Anterior  'portion  of  the  frontal  lobes — sometimes  psychical 
disturbances ;  often  no  special  symptoms. 

Temporal  lobe,  first  and  second  convolutions  {left  side) — word- 
deafness. 

Parietal  lobe — sensory  disturbances  on  opposite  side  of  body. 

Angular  and  supramarginal gyri  (left  side) — word-blindness 
and  apraxia. 

OccipAtal  lobe — hemianopsia,  and  sometimes  word-blindness 
and  mind-blindness. 

Corpus  striatum — large  lesions  produce  hemiplegia  from 
pressure  on  the  internal  capsule. 

Optic  thalamus — large  lesions  may  produce  hemianeesthesia 
from  pressure  upon  the  posterior  limb  of  the  internal  capsule, 
and  sometimes  hemianopsia. 

Corpora  quadrigemina — dilatation  and  immobility  of  the 
pupils,  loss  of  coordination,  disordered  ocular  movements, 
and  hemianopsia. 

Cms  cerebri — hemiplegia  on  one  side,  and  paralysis  of  the 
oculo-motor  nerve  on  the  other. 

Pons — paralvsis  of  the  cranial  nerves,  and  in  many  cases 
hemiplegia  and  hemianesthesia  on  one  side,  and  facial  paralysis 
on  the  other.     Bilateral  lesions  may  produce  general  paralysis. 

Internal  cajjsule  (middle  third) — hemiplegia  on  the  opposite 
side.     Posterior  third — hemiansesthesia  on  the  opposite  sitle. 

Medulla — paralysis  of  the  cranial  nerves,  difficult  articu- 
lation, cardiac  and  respiratory  disturbances,  vomiting,  and 
sometimes  hemiplegia. 

Cerebellum  (middle  lobe)  —  staggering  gait,  vomiting, 
severe  vertigo,  headache,  double  optic  neuritis,  and  tremors 
or  tonic  spasms.  Paralysis  may  result  from  pressure  on  the 
pyramidal  tracts. 

Pkogxosis. — Always  grave.  When  the  tumor  is  not 
gummatous,  and  is  not  suitable  for  operative  interference, 


ABSCESS    OF    THE    BRAIN.  ,369 

the   prognosis   is  absolutely  unfavorable.     The  duration  is 
from  a  few  months  to  several  years. 

Treatment. — Localized  cortical  growths,  which  are  not 
malignant  or  syphilitic,  are  suitable  for  operative  interference. 
In  cerebral  gumma  inunctions  of  mercury  should  be  employed, 
and  mercury  and  iodide  of  potassium  given  by  the  mouth.  In 
other  cases  the  treatment  is  palliative.  Cold  applications  to 
the  head,  bromides,  antipyrin,  and  morj^hine  are  required  t< 
relieve  pain. 

ABSCESS  OF  THE  BRAIN. 

( Suppurative  Encephalitis . ) 

Etiology. — (1)  It  may  be  traumatic.  (2)  It  may  be  se- 
condary to  suppurative  inflammation  of  adjacent  parts,  as 
caries  of  the  temporal  bone  following  otitis  media.  (3)  It 
may  be  secondary  to  some  distant  focus  of  suppuration,  as  in 
pulmonary  abscess,  hepatic  abscess,  ulcerative  endocarditis. 
(4)  It  may  follow  one  of  the  infectious  fevers. 

Pathology. — The  abscess  varies  in  size  from  a  pea  to  one 
large  enough  to  fill  an  entire  hemisphere.  The  surrounding 
tissues  are  hypersemic,  oedematous,  and  more  or  less  infiltrated. 
In  the  acute  form  the  abscess  is  diffuse,  but  in  lono'-standins;' 
cases  the  pus  is  encapsulated  by  a  thick  fibrous  sac.  The 
temporo-sphenoidal  lobe  and  the  cerebellum  are  the  most 
frequent  seats.  Abscesses  secondary  to  distant  foci  of  sup- 
puration are  commonly  multiple. 

Symptoms. — Abscesses  following  injury  frequently  run  an 
acute  course,  and  are  characterized  by  high  fever,  rigors,  head- 
ache, delirium,  convulsions,  vomiting,  and  coma. 

In  chronic  cases  the  general  symptoms  are  headache,  irrita- 
bility, mental  impairment,  vertigo,  vomiting,  irregular  fever, 
stupor,  pallor,  and  loss  of  flesh  and  strength.  The  focal 
phenomena  vary  with  the  location  of  the  abscess.  Involve- 
ment of  the  motor  area  may  be  attended  with  convulsions  or 
paralysis  in  one  limb ;  of  the  temporo-sphenoidal  lobe,  with 
deafness,  and  perhaps  aphasia ;  of  the  occipital  lobe,  with 
hemianopia;  of  the  cerebellum,  with  persistent  vomiting  and 
loss  of  coordination. 
24 


370  DISEASES   OF    THE    NERVOUS   SYSTEM. 

Diagnosis.  Cerebral  Tumors. — The  history  of  traumatism 
or  of  some  primary  suppurating  disease,  such  as  otitis,  bron- 
chiectasis, empyema,  ulcerative  endocarditis ;  the  presence  of 
fever,  and  the  absence  of  optic  neuritis  will  indicate  abscess. 

Acute  cases  can  rarely  be  distinguished  from  suppurative 
meningitis. 

Prognosis. — Grave.  When  the  focal  symptoms  indicate 
involvement  of  an  accessible  region  like  the  motor  area, 
temporo-sphenoidal  lobe,  or  cerebellum,  operative  interference 
affords  considerable  hope  of  success. 

Treatment. — When  the  abscess  is  located  in  one  of  the 
regions  specified,  the  skull  should  be  trephined  and  the  pus 
evacuated.  In  other  cases  the  application  of  wet  cups  to  the 
neck,  of  ice-bags  to  the  head,  and  the  internal  use  of  opium, 
bromide  of  potassium,  or  of  chloral,  may  temporarily  relieve 
the  distress. 

CRETINISM. 

Definition. — A  congenital  affection,  characterized  by  a 
lack  of  physical  development,  an  abnormal  condition  of  the 
thyroid  gland,  myxoedema,  and  idiocy  or  imbecility. 

Etiology. — Beyond  heredity  no  cause  is  known.  The 
condition  is  endemic  in  the  Alps  and  Pyrenees.  Sporadic 
cases  are  also  observed  in  other  parts  of  the  world. 

Symptoms.  Endemic  Cretinism.  —  The  stature  is  short 
(three  or  four  feet) ;  the  head  is  large,  flat  antero-posteriorly 
and  broad  laterally  ;  the  eyes  are  wide  apart ;  the  nose  is  flat; 
the  lips  are  thick ;  the  tongue  is  large  and  may  protrude  from 
the  mouth ;  the  chest  is  narrow  ;  the  belly  is  prominent ;  the 
fingers  are  short ;  the  genitalia  are  not  developed ;  the  sub- 
cutaneous tissues,  especially  at  the  root  of  the  neck,  are 
thickened  from  mucoid  or  fatty  deposits ;  the  thyroid  gland  is 
frequently  enlarged ;  and  the  mental  condition  is.  that  of  idiocy. 

Sporadic  cases  present  the  same  features,  but  the  thyroid, 
instead  of  being  larger,  is  often  atrophied. 

Congenital  conditions  presenting  to  a  limited  extent  the 
phenomena  of  cretinism,  are  termed  cretinoid. 

Treatment. — Encouraging  results  have  followed  the  use 
of  an  extract  of  the  thyroid  gland. 


SPINAL    LEPTOMENINGITIS.  371 

SPINAL  LEPTOMENINGITIS. 

(Spinal  Meningitis.) 

Definition. — An  inflammation  of  the  spinal  pia  mater  not 
associated  with  infectious  cerebro-spinal  meningitis. 

Etiology. — The  infectious  fevers,  exposure  to  cold  and  wet, 
traumatism,  and  tuberculosis  are  the  etiological  factors. 

Pathology.  Acute  Form. — The  membranes  are  opaque, 
thickened,  congested,  and  adherent.  The  fluid  in  the  arach- 
noid space  is  increased.  In  very  acute  cases  there  is  more  or 
less  purulent  infiltration.  The  periphery  of  the  cord  is  al- 
ways involved. 

Chronio  Form. — The  membranes  are  very  thick  and  fused 
into  one  homogeneous  fibrous  mass. 

Symptoms.  Aeute  Form. — The  disease  may  begin  with  a 
chill,  which  is  followed  by  moderate  fever.  There  is  intense 
pain  in  the  back  radiating  along  the  course  of  the  nerves. 
The  back  is  exquisitely  tender.  The  spinal  muscles  are  rigid 
and  contracted,  sometimes  so  much  so  as  to  induce  opisthot- 
onos. The  reflexes  are  increased.  When  the  exudate  is 
sufficient  to  make  considerable  pressure  on  the  cord,  paralytic 
phenomena  develop,  such  as  slight  anaesthesia  and  partial 
paralysis  of  the  extremities. 

There  are  no  cerebral  symptoms  unless  the  meninges  of  the 
brain  are  involved. 

Diagnosis.  Myelitis. — In  this  affection  there  are  marked 
paralysis  and  anaesthesia ;  involvement  of  the  bladder  and 
rectum  ;   and  the  formation  of  bedsores 

Rheumatism  of  the  Muscles  and  Fibrous  Tissues  of  the  Back. — 
In  this  condition  the  joints  are  involved;  the  urine  is  highly 
acid ;  the  pain  does  not  follow  the  nerve-trunks ;  and  the 
sj'mptoms  yield  to  the  salicylates. 

Tetanus. — The  presence  of  a  wound  ;  the  absence  of  fever  ; 
the  early  involvement  of  the  jaw;  and  the  absence  of  exquisite 
tenderness  in  the  back  will  separate  tetanus  from  meningitis. 

Peognosis. — Extremely  grave.  Recovery  sometimes  fol- 
lows, but  rarely  without  partial  paralysis. 

Chronic  Leptomeningitis. — Pain  in  the  back ;    stiffness  of 


372  DISEASES    OF    THE    NERVOUS    SYSTEM. 

muscles ;  bypersesthesia  and  parsesthesia  of  the  lower  extremi- 
ties, but  rarely  any  anaesthesia ;  some  loss  of  power ;  and 
increased  reflexes. 

Treatment. — An  ice-bag,  leeches,  or  cups  may  be  applied 
to  the  spine.  Sedatives  like  chloral,  bromides,  and  morphine 
are  usually  required.  Warm  baths  relieve  the  pain  and  lessen 
the  rigidity.     Ergot  and  iodide  of  potassium  are  recommended. 

If  the  acute  symptoms  subside,  iodide  of  potassium  may  be 
administered  internally ;  blisters  and  mercurial  inunctions 
may  be  applied  to  the  spine,  and  massage  and  electricity  to 
the  affected  muscles. 

CHIiONIC  SPINAL  PACHYMENINGITIS. 

(Cervical  Hypertrophic  Pachymeningitis,  Internal 
Pachymeningitis . ) 

Definition. — A  chronic  inflammatory  affection  of  the  dura 
mater,  characterized  by  severe  pains  in  the  head,  shoulders, 
arms,  and  loins,  followed  by  paresis,  wasting,  and  ansesthesia. 

ETiOLOGY.^Male  sex,  middle  life,  prolonged  exposure  to 
cold,  lowered  vitality, spinal  concussion,  alcoholism, and  syphilis 
are  predisposing  factors.  It  may  be  secondary  to  inflammation 
of  neighboring  structures,  such  as  the  vertebrae  in  Pott's 
disease. 

Pathology. — The  membranes  are  thickened,  opaque,  and 
adherent ;  the  vessels  are  dilated ;  and  the  spinal  fluid  is  in- 
creased. In  advanced  cases  the  membranes  are  glued  together 
and  form  a  thick,  homogeneous,  fibrous  mass.  The  cervical 
region  is  most  commonly  affected.  The  inflammation  may 
extend  to  the  cord  and  peripheral  nerves. 

Symptoms. — Sharp  pains  radiating  into  the  head,  shoulders, 
arms,  and  loins,  followed  by  loss  of  power,  anaesthesia,  wast- 
ing, and  rigidity,  particularly  in  the  upper  extremities.  When 
the  lower  part  of  the  cord  is  involved  the  same  phenomena 
are  observed  in  the  legs,  and  the  knee-jerk  is  increased".  The 
duration  of  the  disease  is  several  years. 

Diagnosis. —  Chronic  Poliomyelitis. — The  absence  of  pain 
and  of  anaesthesia  will  separate  poliomyelitis  from  pachy- 
meningitis. 


ACUTE    MYELITIS.  373 

Multiple  Neuritis. — In  this  aflPection  the  pain  is  less  marked 
in  the  back  and  more  marked  in  the  extremities,  and  the  nerve- 
trunks  are  tender  on  pressure. 

Spinal  Irritation. — In  this  condition  the  spine  is  tender  at 
certain  spots,  and  there  is  no  radiating  pain,  anaesthesia,  or 
wasting. 

Prognosis. — This  depends  on  the  extent  and  cause.  When 
the  involvement  is  slight  or  is  due  to  syphilis,  the  prognosis 
should  be  guardedly  favorable. 

Treatment. — Absolute  rest.  Tonics  are  often  indicated. 
Counter-irritation  should  be  made  along  the  cord  by  frequent 
blisters  or  the  actual  cautery.  Morphine,  antipyrin,  or  phena- 
cetin  may  be  required  for  the  relief  of  pain.  Iodide  of  potas- 
sium may  be  administered  for  its  absorbent  effect,  and  in 
syphilitic  cases  it  should  be  given  freely  in  conjunction  with 
some  mercurial. 

ACUTE  MYELITIS. 

Definition. — An  acute  inflammation  of  the  substance  of 
the  cord,  characterized  by  marked  disturbances  of  motion,  sen- 
sation, and  nutrition. 

Varieties. — When  only  a  transverse  section  is  involved 
the  condition  is  termed  transverse  myelitis.  When  a  large 
vertical  section  is  affected  the  disease  is  termed  diffuse  myelitis. 
When  the  gray  matter  is  especially  involved  it  is  termed  central 
myelitis. 

Etiology. — Traumatism;  exposure  to  cold,  especially  when 
the  body  is  overheated ;  over-exertion;  alcoholism;  syphilis;  or 
the  infectious  fevers  may  induce  it.  It  is  sometimes.secondary 
to  a  hemorrhage  or  a  morbid  growth  in  the  cord. 

Pathology. — The  membranes  are  usually  injected  and 
opaque.  The  substance  of  the  cord  is  red  and  soft,  and  the 
line  of  demarcation  between  the  gray  and  white  matter  is  in- 
distinct. In  very  acute  cases  the  substance  of  the  cord  may 
flow  out  as  a  reddish,  creamy  fluid  when  the  membranes  are 
cut.  Occasionally  there  are  conspicuous  hemorrhagic  effusions 
(hsematomyelitis). 

Microscopic  examination  reveals  destruction  of  the  nerve- 


374  DISEASES    OF    THE    ]SERVOUS    SYSTEM. 

elemeuts,  and  in  their  place  granular  debris,  fat-globules,  red 
blood -corpuscles,  and  leucocytes. 

Symptoms.  Acute  Transverse  Myelitis. — Moderate  fever 
(101°-103°),  loss  of  appetite,  coated  tongue,  and  constipa- 
tion, followed  by  pain  in  the  back  radiating  into  the  limbs. 
With  the  pain  there  are  often  various  forms  of  parsesthesia, 
as  numbness,  tingling,  burning,  etc.  The  muscles  may  be  the 
seat  of  tremors  or  of  convulsive  seizures.  There  is  frequently 
a  sense  of  painful  constriction — "  girdle  pain" — at  the  level  of 
the  disease.  Paralysis  soon  develops,  and  may  become  more 
or  less  complete.  The  reflexes  are  generally  increased  when 
the  lesion  is  above  the  lumbar  enlargement;  but  if  the  latter 
is  involved  they  are  lost.  The  paralyzed  muscles  are  flabby, 
but  do  not  yield  the  reactions  of  degeneration ;  when,  how- 
ever, the  reflexes  are  exaggerated  the  muscles  often  become 
rigid  and  contracted.  At  first  there  may  be  retention  of 
urine  and  feces,  but  later  there  is  frequently  incontinence. 
Anaesthesia  is  more  or  less  complete.  Bedsores  soon  develop 
and  add  to  the  distress  of  the  patient. 

Death  may  result  in  a  few  days  from  extension  upward  and 
involvement  of  the  respiratory  muscles.  In  many  cases  life 
is  prolonged  for  several  weeks,  death  finally  resulting  from 
exhaustion  induced  by  bedsores  and  cystitis.  In  rare  cases 
there  is  a  spontaneous  arrest  of  the  inflammation,  and  slow 
recovery  follows,  attended  with  partial  paralysis. 

Acute  Central  Myelitis  — This  resembles  the  former,  but  the 
trophic  disturbances  are  much  more  marked  and  the  dura- 
tion is  shorter.  The  disease  is  characterized  by  moderate  fever 
and  its  associated  phenomena,  pain  in  the  back,  complete  loss 
of  power  and  of  sensation,  loss  of  reflexes,  incontinence  of 
urine  and  feces,  rapid  wasting  of  the  muscles,  and  the  early 
development  of  bedsores.  The  disease  invariably  proves 
fatal  in  from  one  to  two  weeks. 

Diagnosis.  Acute  Poliomyelitis. — In  this  disease  the  blad- 
der and  rectum  are  not  involved,  and  there  are  no  sensory 
disturbances. 

Landry's  Disease,  or  Acute  Ascending  Paralysis. — In  this 
affection  trophic  disturbances  are  absent ;  the  bladder  and 
rectum  are  not  involved ;  and  the  loss  of  sensation  is  slight. 


CHRONIC    MYELITIS.  375 

Multiple  Neuritis. — The  "  girdle  pain"  is  absent ;  the  sphinc- 
ters are  not  afFeoted  ;  bedsores  are  rare ;  and  pain  is  more 
marked  in  the  extremities  than  in  the  back. 

Meningitis — The  girdle  pain  is  absent;  the  sphincters  are 
not  affected  ;  the  irritative  phenomena  are  more  marked  than 
the  paralytic. 

Hemorrhage  into  the  Cord. — The  paralysis  develops  ab- 
ruptly. ,  .  , 

Prognosis.  —  Always  extremely  grave.  Acute  central 
myelitis  is  invariably  fatal.  In  other  cases  recovery  attended 
with  partial  paralysis  occasionally  follows. 

Treatment. — If  possible,  tlie  patient  should  be  placed  on 
a  water-bed.  To  delay  the  formation  of  bedsores  extreme 
cleanliness  is  essential.  Both  in  retention  and  incontinence  of 
urine  the  catheter  should  be  used  twice  daily.  In  incontinence 
of  urine  and  feces  the  discharges  should  be  received  on  cotton- 
wool or  oakum,  which  should  be  frequently  renewed  and  the 
parts  thoroughly  cleansed.  In  the  beginning  an  ice-bag  or 
wet  cups  may  be  applied  to  the  spine.  Such  remedies  as  ergot, 
belladonna,  quinine,  and  mercury  are  frequently  employed,  but 
they  seem  to  exert  little  influence.  If  recovery  should  follow, 
massage,  electricity,  and  strychnine  may  be  employed  with  the 
hope  of  restoring  power  to  the  paralyzed  muscles. 

CHRONIC  MYELITIS. 

Etiology.— Middle  life,  continued  exposure  to  cold  and 
wet,  syphilis,  alcoholism,  gout,  traumatism,  and  excesses  are  the 
predisposing  factors.     It  may  be  secondary  to  Pott's  disease. 

Pathology. — The  membranes  are  opaque  and  adherent. 
The  whole  cord  has  a  grayish  color ;  it  is  firmer  than  normal 
and  somewhat  contracted. 

Microscopic  examination  reveals  destruction  of  nerve-ele- 
ments, and  their  replacement  by  an  overgrowth  of  connective 
tissue. 

Symptoms. — The  disease  begins  gradually  with  numbness, 
tingling,  or  burning  in  the  lower  extremities,  followed  by  a  loss 
of  power  and  sensation.  The  reflexes  are  generally  exagger- 
ated.    The  sphincters  soon  become  involved.     The  muscles  do 


376  DISEASES    OF    THE    XERVOrS   SYSTEM. 

not  waste  until  the  disease  is  far  advanced.  As  in  other 
organic  affections  of  the  cord,  there  is  often  a  sense  of  constric- 
tion, or -"girdle  paiu,"  at  the  level  of  the  disease.  The  disease 
progresses  very  slowly,  the  duration  being  from  six  months  to 
ten  years. 

Diagnosis. — The  diagnosis  rests  on  the  gradual  develop- 
ment of  symptoms  indicating  a  general  involvement  of  the  cord. 

Treatment. — The  patient  should  be  put  at  rest;  tonics 
are  often  indicated  ;  counter-irritation  to  the  spine  by  repeated 
blisters  or  applications  of  the  actual  cautery,  often  yields  good 
results.  The  frequent  use  of  tepid  baths  is  also  beneficial. 
The  special  remedies  which  have  been  recommended  are 
arsenic,  strychnine,  phosphorus,  nitrate  of  silver,  mercury,  and 
iodide  of  potassium.  AYhen  there  is  a  suspicion  of  syphilis 
the  last  two  remedies  should  be  given  a  thorough  trial. 


SCLEROSIS  OF  THE  SPII^AL  CORD. 

Definition. — A  degenerative  affection  of  the  spinal  cord, 
characterized  anatomically  by  an  atrophy  of  the  nerve-elements 
and  an  overgrowth  of  connective  tissue. 

Etiology. — Middle  life,  male  sex,  syphilis,  alcoholism, 
mineral  poisoning,  excesses,  and  continued  exposure  to  cold 
and  wet  are  the  usual  causes. 


Locomotor  Ataxia. 

(Locomotor  Ataxy,  Tabes  Dorsalis,  Posterior  Sclerosis.) 

Definition. — A  degenerative  affection  of  the  lower  sen- 
sory neurons,  involving  the  spinal  ganglia,  posterior  roots, 
and  posterior  columns  of  the  cord,  and  characterized  by  inco- 
ordination, loss  of  deep  reflexes,  disturbances  of  nutrition  and 
of  sensation,  and  various  ocular  phenomena. 

Pathology. — The  membranes  over  the  posterior  columns 
are  often  oj^aque  and  adherent.  The  posterior  columns  have 
a  grayish  color,  and  are  firm  and  shrunken. 

Microscopic  examination  reveals  atrophy  of  the  nerve- 
fibres  and  an  overgrowtli  of  connective  tissue.     Degenerative 


SCLEROSIS    OF    THE    SPINAL    CORD.  377 

changes  are  also  observed  in  the  posterior  roots  of  their 
ganglia.  Not  infrequently  the  process  involves  the  basal 
ganglia  of  the  brain  and  cranial  nerves. 

Symptoms.  Motor  Phenomena.  —  One  of  the  earliest 
symptoms  is  loss  of  coordination.  This  is  first  manifested 
by  unsteadiness  when  the  patient  walks  in  the  dark.  When 
he  stands  erect,  with  the  eyes  closed  and  feet  together,  he 
staggers  and  tends  to  fall  (Romberg's  symptom).  When  the 
arms  are  aifected  there  is  inability  to  perform  work  requiring 
delicate  coordination,  such  as  writing  and  piano-playing. . 
This  loss  of  coordination  in  the  upper  extremities  becomes 
conspicious  when  the  patient,  while  his  eyes  are  closed,  at- 
tempts to  touch  the  tip  of  his  nose. 

The  gait  is  characteristic ;  in  walking  he  raises  his  feet  high, 
throws  them  forwards,  and  brings  them  down  forcibly  in  such 
a  way  that  the  whole  sole  strikes  the  floor  at  once.  Although 
the  patient  may  be  unable  to  walk  or  to  use  his  hands  with 
precision,  there  is  no  actual  loss  of  power. 

Sensory  Phenomena. — Pain  is  rarely  absent ;  it  is  sharp  and 
lancinating  in  character,  and  appears  in  paroxysms.  It  usually 
involves  the  extremities,  but  sometimes  it  attacks  the  stomach 
and  is  accompanied  with  obstinate  vomiting.  The  term  gastric 
crisis  is  applied  to  this  phenomenon. 

Crises  may  occur  in  other  organs,  notably  the  larynx,  where 
they  are  manifested  by  intense  dyspnoea  and  stridulous  breath- 
ing. Various  forms  of  parsesthesia  are  observed,  such  as 
tingling,  numbness,  "  pins  and  needles,"  and  the  like.  Irregu- 
lar areas  of  ansesthesia  are  frequently  distributed  over  the  body. 

Reflexes. — The  patellar  reflex  is  lost  very  early  in  the 
disease.  The  pupil  fails  to  respond  to  light  while  it  still 
accommodates  for  distance  (Argyll-Robertson  pupil). 

PJye  Phenomena. — The  most  important  are  diplopia,  con- 
tracted pupils,  dimness  of  vision  from  optic  atrophy,  and 
paresis  of  the  ocular  muscles. 

Trophic  Phenomena. — The  most  curious  are  the  .  so-called 
arthropathies,  which  consist  of  enlargement  of  the  joints, 
associated  with  serous  effusions,  atrophy  of  the  heads  of  the 
bone,  erosion  of  the  cartilages,  and  calcification  of  the  liga- 
ments.    These  articular  changes  sometimes  lead  to  luxations. 


378  DISEASES   OF   THE   NERVOUS  SYSTEM. 

Perforating  ulcer  of  the  foot  is  sometimes  observed. 

Other  symptoms  sometimes  observed  are :  loss  of  sexua 
power,  paralysis  of  the  sphincters,  epileptiform  seizures,  and 
dementia. 

DlSEASES  with  which  LOCOlsrOTOR  ATAXIA  MAY  BE  ASSO- 
CIATED.— Spastic  paraplegia,  multiple  neuritis,  paretic  demen- 
tia, and  chronic  poliomyelitis. 

Diagnosis.  Multiple  Neuritis.  —  In  this  affection  the 
peripheral  nerves  are  tender;  the  muscles  may  yield  the 
reactions  of  degeneration ;  the  pain  is  not  lancinating  like 
that  of  ataxia ;  and  the  Argyll-Robertson  pupil  is  absent. 

Tumor  of  the  Cerebellum. — In  this  condition  the  reflexes  are 
not  abolished,  lightning  pains  are  absent,  and  instead  there 
are  persistent  vomiting,  headache,  and  optic  neuritis. 

Gastralgia. — A  gastric  crisis  may  be  mistaken  for  gastralgia, 
but  the  associated  phenomena  of  locomotor  ataxia  will  prevent 
an  error  in  diagnosis. 

Prognosis. — Generally  unfavorable,  although  arrest  and 
even  improvement  are  not  infrequent.  The  duration  is  in- 
definite. 

Treatment. — The  patient  should  be  placed  under  the  best 
hygienic  conditions.  Rest  is  desirable.  In  the  early  stage  a 
prolonged  voyage  may  produce  excellent  results.  The  diet 
must  be  nutritious,  but  easily  assimilable.  Excesses  of  ail 
kinds  must  be  rigidly  prohibited.  Tonics  are  frequently  in- 
dicated. When  there  is  a  suspicion  of  syphilis,  iodide  of 
potassium  should  be  given  in  full  doses.  In  other  cases  iodide 
of  potassium  in  small  doses,  mercury,  and  arsenic,  are  the 
most    reliable    remedies.      The   following    pill    may   prove 

useful : — 

^   Sodii  arsenat., 

Zinc,  phosphid.,  aa  gr.  ij  ; 
Hydrarg.  iodid.  rub.,  gr.  j. — M. 
Yt.  in  pil.  ISTo.  xxx. 
Sig. — One,  three  times  daily  after  meals. 

Frankel's  method  of  reteaching  the  lost  power  of  coordina- 
tion by  graduated  exercises  is  of  decided  value. 

The  Pains. — When  very  intense,  morphine  will  be  re- 
quired ;  in  other  cases  antipyrin,  phenacetin,  and  cannabis 
indica  are  sometimes  efficient. 


SCLEROSIS    OF    THE    SPINAL    COED.  379 

^  Antipyrin,  gj  ; 
Syr.  zingiber.,  f^j  ; 

Aquse  q.  s..  ad  f^iv.— M.     (Gekmain  See.) 
Sig. — A  teaspoonful  every  one  to  four  hours  for  three  to  six 
doses. 

The  laryngeal  crises  may  be  relieved  by  the  inhalation  of 
chloroform  or  amyl  nitrite. 

Primary  Spastic  Paraplegia. 

(Lateral  Sclerosis,  Antero-lateral  Sclerosis.) 

Definition. — A  nervous  affection  probably  dependent 
upon  sclerosis  of  the  lateral  columns,  and  characterized  by 
loss  of  power,  increased  reflexes,  and  a  spastic  condition  of  the 
muscles. 

Pathology. — There  is  probably  a  sclerosis  of  the  lateral 
columns  of  the  cord. 

Symptoms. — Loss  of  power  is  generally  the  first  symptom. 
This  begins  in  the  lower  extremities  and  increases  very  slowly. 
The  knee-jerk  is  exaggerated,  and  in  most  cases  ankle-clonus 
can  be  elicited.  When  put  in  use  the  muscles  become  stiff,  or 
spastic,  and  when  the  disease  is  fully  developed  the  gait  is 
peculiar.  In  walking  the  knees  are  drawn  together,  the  legs 
drag  behind,  and  the  toes  catch  the  ground. 

The  muscles  do  not  waste,  but  rather  tend  to  become  hyper- 
trophied  from  continued  reflex  stimulation.  The  sphincters 
are  ultimately  affected.  Sensation  is  generally  undisturbed, 
but  subjective  phenomena  like  numbness  and  tingling  may  be 
observed.  The  upper  extremities  are  not  often  involved,  but 
finally  loss  of  power  and  rigidity  may  develop  in  them  also. 

Peognosis. — Unfavorable.  In  rare  instances  the  disease  is 
arrested. 

The  duration  is  indefinite. 

Teeatment. — The  general  treatment  is  the  same  as  in 
locomotor  ataxia.  For  the  spasmodic  condition  of  the  mus- 
cles, rubbing,  warm  baths,  and  the  following  remedies  are 
recommended :  bromide  of  potassium,  calabar  bean,  and  bel- 
ladonna. 


380  DISEASES    OF    THE    NERVOUS    SYSTEM. 

Amyotrophic  Lateral  Sclerosis. 

Definition. — A  nervous  aifectlon  characterized  anatomic 
cally  by  a  degeneration  of  the  lateral  columns  and  adjacent 
gray  matter,  and  manifested  clinically  by  loas  of  power, 
wasting,  and  a  spastic  condition  of  the  muscles. 

PATHOLoav. — The  disease  apparently  depends  upon  a 
sclerosis  involving  mainly  the  anterior  horns  of  the  gray  matter 
and  the  antero-lateral  columns. 

Symptoms. — Loss  of  power  and  wasting,  usually  beginning 
in  the  small  muscles  of  the  hand,  and  gradually  spreading  over 
the  entire  body.  The  reflexes  are  exaggerated.  AVhen  the 
muscles  are  put  into  use,  they  become  more  or  less  rigid,  or 
spastic.  The  degenerative  process  extends  upwards  until  it 
involves  the  medulla,  when  symptoms  of  bulbar  palsy  appear. 

Diagnosis. — The  muscular  rigidity  and  exaggerated  reflexes 
will  distinguish  it  from  pure  progressive  muscular  atrophy. 

Prognosis. — Unfavorable. 

Treatment. — Such  remedies  as  arsenic  and  iodide  of 
potassium  are  recommended,  but  they  usually  prove  useless. 
The  spastic  condition  is  improved  by  massage. 

Ataxic  Parai)legia. 

Definition. — ^A  sclerotic  aifection  of  the  posterior  and 
lateral  columns  manifesting  symptoms  of  both  locomotor  ataxia 
and  spastic  paraplegia. 

Symptoms. — It  resembles  spastic  paraplegia  in  the  loss  of 
power,  spastic  condition  of  the  muscles,  increased  reflexes,  and 
absence  of  sensory  disturbances ;  and  locomotor  ataxia  in  the 
distinct  loss  of  coordination. 

Disseminated  Cerebro-spinal  Sclerosis. 

(Multiple  Sclerosis,  Insular  Sclerosis.) 

Definition. — A  chronic  nervous  disease  characterized  ana- 
tomically by  patches  of  sclerosis  of  varying  size  scattered 
through  the  brain  and  cord. 

Etiology. — The  causes  which  lead  to  other  scleroses  of  the 
cord  may  induce  this  disease;  the  infectious  fevers,  however^ 


SCLEEOSIS    OF    THE    SPINAL    COED.  381 

are  assigned  a  prominent  place  in  its  etiology.  It  is  more 
commonly  observed  in  younger  people  than  is  locomotor  ataxia 
or  lateral  sclerosis. 

Patholgy. — Areas  of  firm,  gray,  sclerotic  tissue,  of  various 
sizes  and  shapes,  are  found  through  the  brain  and  cord. 

Symptoms. — The  spinal  symptoms  may  resemble  either 
locomotor  ataxia  or  lateral  sclerosis,  according  as  the  posterior 
or  lateral  columns  are  chiefly  affected.  The  characteristic 
symptoms  are  loss  of  power,  usually  most  marked  in  the  legs ; 
increased  reflexes;  vague  pains;  a  coarse  tremor  developed  on 
movement  (volitional  tumor) ;  a  slow,  hesitating,  "  scanning" 
speech  ;  nystagmus — tremor  of  the  eyeballs ;  and  mental  im- 
pairment. Sensory  and  trophic  disturbances  are  generally 
absent. 

Diagnosis. — Disseminated  sclerosis  may  be  mistaken  for 
paralysis  agitans,  but  the  latter  disease  develops  in  late  life ; 
the  tremor  is  fine,  rarely  involves  the  head,  and  is  not  made 
worse  by  use  of  the  muscles ;  and  nystagmus  is  absent. 

Peognosis. — Unfavorable.  The  duration  is  indefinite,  and 
long  remissions  with  improvement  of  the  symptoms  are  not 
uncommon. 

Teeatment. — The  general  treatment  is  the  same  as  that 
for  posterior  sclerosis.  Bromides,  hyoscine,  hyoscyamine,  and 
belladonna  have  been  recommended  for  the  tremors. 

Hereditary  Ataxia. 

(Friedreich's  Disease.) 

Definition. — A  sclerotic  affection  of  the  spinal  cord,  occur- 
ring in  several  children  of  the  same  family,  and  characterized 
by  symptoms  resembling  locomotor  ataxia. 

Etiology. — The  greatest  number  of  cases  develop  between 
the  second  and  fifteenth  years.  Some  can  be  traced  to  heredi- 
tary influence  ;  in  others  a  cause  cannot  be  ascertained. 

Pathology — Sclerosis  of  the  posterior  and  lateral  columns 
cf  the  cord. 

Symptoms. — Loss  of  coordination  in  the  arm  and  legs, 
nystagmus,  irregular  jerking  movements  of  the  hands,  loss  of 


382  DISEASES    OF    THE    NERVOUS   SYSTEM. 

reflexes,  a  scanning  speech,  spinal  curvature,  equino-varus  (heel 
raised  and  the  sole  turned  in). 

It  diflfers  from  locomotor  ataxia  in  the  absence  of  sharp 
pains,  of  anaesthesia,  and  of  the  Argyll-Robertson  pupil,  and 
in  the  occurrence  of  irregular  movements  of  the  hands,  nystag- 
mus, scanning  speech,  and  equino-varus. 

Prognosis. — Unfavorable.     The  duration  is  many  years. 

SYKINGO-MYELIA. 

Definition. — A  chronic  affection  of  the  spinal  cord  char- 
acterized anatomically  by  the  formation  of  a  cavity  in  its 
substance,  and  clinically  by  atrophy  of  certain  muscles,  pecu- 
liar disturbances  of  sensation,  and  various  trophic  disorders. 

Etiology. — It  is  much  more  common  in  males  than  fe- 
males. Eighty  per  cent,  of  the  cases  occur  between  the  ages 
of  ten  and  forty  years.  Traumatism  or  one  of  the  infectious 
fevers  may  excite  it. 

Pathology. — The  disease  begins  as  an  overgrowth  of 
the  embryonic  neuroglia.  The  cavity-formation  is  a  second- 
ary process,  and  is  brought  about  by  degeneration  of  the 
gliomatous  tissue,  or  possibly  in  some  instances  by  hemor^ 
rhage.  The  cervical  and  upper  dorsal  regions  are  the  usual 
seats  of  the  lesion.  The  cavity  lies  in  the  gray  matter,  and 
may  be  in  the  position  of  the  central  canal  or  somewhat  pos- 
terior to  it.  Secondary  degenerations  are  frequently  observed 
in  the  anterior  or  posterior  horns  or  in  the  anterior  or  pos- 
terior columns. 

Symptoms. — The  disease  usually  attacks  the  upper  ex- 
tremities, the  chief  symptoms  being  :  Wasting  of  the  muscles  ; 
fibrillary  tremors ;  loss  of  painful  and  thermic  sensations, 
while  tactile  sensation  is  preserved  or  but  slightly  aflFected 
(dissociation  symptom) ;  lateral  spinal  curvature  ;  and  various 
trophic  disturbances,  such  as  arthropathies,  fissures,  ulcers, 
and  gangrene.  Such  eye  symptoms  as  nystagmus,  inequality 
of  pupils  and  narrowing  of  the  visual  fields  are  frequently 
observed.  In  many  instances  symptoms  of  lateral  sclerosis, 
posterior  sclerosis,  or  bulbar  disease  are  superadded. 

The  distin(!tive  features  oi Morvan^s  disease  (probably  a  form 
of  syringo-myelia)  are  tactile  anaesthesia  and  painless  felons. 


ACUTE   ANTERIOR    POLIOMYELITIS.  383 

Diagnosis. —  Cervical  pachymeningitis  is  more  painfalj  and 
the  anaesthesia  includes  tactile  sensation.  In  'progressive 
muscular  atrophy  and  amyotrojAic  laieral  sclerosis  sensory 
symptoms  are  wanting.  Leprosy  may  be  recognized  by  loss 
of  tactile  sensation,  discoloration  of  skin,  nodular  swellings, 
and  presence  of  bacilli  in  the  secretions  of  the  nose  and  eyes 
and  in  the  serum  of  blisters. 

Prognosis. — Unfavorable.  The  duration  is  from  five  to 
twenty  years. 

Treatment. — This  is  necessarily  symptomatic. 

ACUTE  ANTERIOR  POLIOMYELITIS. 

(Infantile    Paralysis,  Atrophic  Spinal  Paralysis.) 

Definition.  —  An  acute  disease,  occurring  almost  exclu- 
sively in  young  children,  characterized  anatomically  by  a  de- 
struction of  the  ganglion-cells  in  the  anterior  gray  horns  of  the 
cord,  and  manifested  clinically  by  abrupt  paralysis  and  rapid 
wasting  of  certain  muscles. 

Etiology.  —  The  greatest  number  of  cases  occur  within 
the  first  three  years,  and  the  disease  is  far  more  common  in 
summer  than  in  winter.  The  sudden  onset,  the  absence  of 
any  known  exciting  cause,  and  the  fact  that  it  has  occurred 
epidemically  suggest  an  infectious  origin. 

Pathology.  —  The  sudden  onset  and  wide-spread  initial 
paralysis  are  probably  due  to  intense  congestion,  and  the  per- 
manent paralysis  and  wasting  to  destruction  of  the  ganglion- 
cells  in  the  anterior  gray  horns.  Microscopic  examination  in 
recent  cases  reveals  ecchymoses,  destruction  of  ganglion-cells, 
and  infiltration  of  leucocytes. 

Examination  long  after  the  development  of  the  paralysis 
reveals  an  absence  or  atrophy  of  the  large  multipolar  cells 
in  the  gray  horns,  and  in  their  stead  an  overgrowth  of  connec- 
tive tissue.  The  anterior  nerve-roots  and  muscles  also  reveal 
degenerative  changes. 

Symptoms. — Genetally  the  onset  is  abrupt ;  often  the  child 
is  put  to  bed  in  apparent  health  and  in  the  morning  is  found 
paralyzed  in  one  or  more  lirabs.  In  some  cases  febrile  symp- 
toms precede  the  attack,  and  more  rarely  the  disease  is  ushered 
in  with  a  chilli  a  convulsion^  or  delirium. 


384  DISEASES    OF    THE    NERVOUS    SYSTEM. 

The  paralysis  at  first  may  be  quite  extensive,  but  more  com- 
monly it  confines  itself  to  certain  groups  of  muscles  in  the 
upper  or  lower  extremities.  The  latter  are  especially  prone  to 
suffer ;  the  affected  muscles  are  relaxed,  and  the  surface  is  cold 
and  often  cyanosed.  The  paralysis  is  peculiar  in  its  irregular 
distribution  and  in  its  tendency  to  improve  spontaneously  up  to 
a  certain  limit.  There  are  no  sensory  disturbances,  no  involve- 
ment of  the  bladder  and  rectum,  and  no  tendency  to  bedsores. 
The  muscles  which  are  permanently  affected  rapidly  waste  and 
ultimately  yield  the  reactions  of  degeneration.  From  con- 
tractures of  the  atrophied  muscles,  and  contraction  of  their 
healthy  antagonists,  various  deformities  develop. 

Diagnosis. — The  abrupt  onset  will  distinguish  it  from  both 
idiopathic  muscular  atrophy  and  progressive  muscular  atrophy. 
The  absence  of  sensory  disturbances,  bedsores,  and  paralysis 
of  the  bladder  and  rectum  will  separate  it  from  myelitis.  The 
presence  of  cerebral  symptoms,  of  choreiform  or  athetoid 
movements  in  the  affected  members,  and  the  absence  of  reac- 
tions of  degeneration  and  of  early  wasting  will  separate  cere- 
bral 'paralysis  of  childhood  from  acute  poliomyelitis. 

Peognosis. — Unless  the  initial  symptoms  are  very  severe, 
the  prognosis,  as  regards  life,  is  good.  In  all  cases  some  of 
the  paralysis  disappears.  Occasionally  the  improvement  is  so 
great  that  the  use'fidness  of  the  member  is  not  impaired  ;  but 
far  more  frequently  the  residual  paralysis  is  sufficient  to  cause 
considerable  deformity  and  disability. 

Treatment. — During  the  acute  stage  the  child  should  be 
confined  to  bed.  To  relieve  the  congestion,  dry  cups  may  be 
applied  to  the  spine  and  ergot  may  be  given  internally.  The 
affected  members  should  be  wrapped  in  flannel. 

After  the  lapse  of  two  or  three  weeks  electrical  treatment 
should  be  instituted;  the  faradic  current  may  be  employed 
when  it  induces  contraction  of  the  affected  muscles,  but  when 
it  excites  no  response  the  galvanic  ciu'rent  must  be  substituted. 
Massage  is  a  very  valuable  adjunct  to  the  electrical  treatment. 
Internally  strychnine  (gr.  -^  to  a  child  of  two  years)  gradually 
increased  is  a  useful  muscular  stimulant.  Massage  and  the 
adjustment  of  mechanical  appliances  will  be  required  to  combat 
deformity  from  contractures. 


PROGRESSIVE    MUSCULAR    ATROPHYo  385 


PROGRESSIVE  MUSCULAR  ATROPHY. 

(Chronic  Spinal  Muscular  Atrophy,  Chronic  Poliomyelitis.) 

Definition. — A  chronic  nervous  affection,  characterized 
anatomically  by  degeneration  of  the  ganglion-cells  of  the  gray 
matter  in  the  cord,  and  manifested  clinically  by  loss  of  power 
and  atrophy  of  corresponding  muscles. 

Etiology. — Male  sex,  middle  life^  and  hereditary  tendency 
are  the  predisposing  causes.  It  sometimes  follows  prolonged 
emotional  excitement,  exposure  to  cold,  traumatism,  and 
syphilis. 

Pathology. — Mici-oscopic  examination  of  the  gray  matter 
of  the  cord  reveals  atrophy  or  complete  absence  of  the  large 
multipolar  cells  in  the  anterior  cornua,  and  an  overgrowth  of 
connective  tissue.  The  anterior  root-fibres  are  also  the  seat  of 
degenerative  changes.  In  some  cases  the  lateral  columns  are 
likewise  sclerosed  (amyotropliic  lateral  sclerosis). 

Examination  of  the  affected  muscles  reveals  atrophy  of  the 
fibres,  fatty  degeneration,  an  overgrowth  of  connective  tissue, 
and  an  absence  of  transverse  striation,  and  instead,  longitudi- 
nal striation. 

Symptoms. — Not  infrequently  prodromal  symptoms  are 
noted  in  the  parts  to  be  affected,  such  as  pain,  coldness,  or 
numbness.  Soon,  loss  of  power  and  wasting  begin  in  the 
small  muscles  of  the  hand,  naaiely,  the  thenar  and  interossei 
muscles.  Although  one  hand  is  usually  affected  before  the 
other,  the  disease  tends  to  become  symmetrical.  Next  to  the 
lilinds  the  muscles  of  the  shoulders  and  arms  slowly  waste,  ren- 
dering the  bony  prominences  marked  ;  and  so  the  disease 
advances  little  by  little  until  the  patient  is  reduced  to  a  mere 
skeleton.  The  hands  assume  a  characteristic  appearance  :  from 
atrophy  of  the  interossei  and  contraction  of  the  long  extensor  and 
flexor  muscles  they  become  "  claw-like."  The  wasted  mus- 
cles are  frequently  the  seat  of  fibillary  tremors.  The  response 
to  the  galvanic  and  faradic  currents  is  diminished,  but  the  re- 
actions of  degeneration  do  not  develop  until  the  disease  is  far 
advanced.  Although  the  patient  may  complain  of  coldness 
25 


386  DISEASES    OF   THE    NERVOUS   SYSTEM. 

and  numbness,  sensation  is  not  impaired.  The  legs  are  not 
involved  until  late,  and  often  escape  entirely. 

The  ^vasting  progresses  very  slowly,  and  death  may  result 
from  some  intercurrent  disease ;  if  such  is  not  the  case,  exten- 
sion to  the  medulla  leads  to  symptoms  of  bulbar  palsy,  such  as 
indistinct  articulation,  inability  to  pucker  the  lips,  difficult 
swallowing,  and  embarrassed  respiration. 

Complications. — It  may  be  associated  with  lateral  sclerosis, 
when  it  is  termed  amyotropklG  lateral  sclerosis.  It  may  lead  to 
bulbar  palsy. 

Diagnosis.  Primary  Muscular  Atrophy. — This  disease 
develops  in  earlier  life,  rarely  begins  in  the  hand,  and  the 
hereditary  tendency  is  more  marked  than  in  poliomyelitis. 

Prognosis. — Always  unfavorable.  The  duration  is  indefi- 
nite. 

Treatment. — Good  hygiene.  Nutritious  food.  Tonics. 
Gowers  claims  good  results  from  the  hypodermic  injection  of 
nitrate  of  strychnine  (gr.  j-^-g-  increased  to  -^-^)  once  daily. 
Massage  and  electricity  yield  no  results. 

BULBAR  PARAXYSIS. 

(Glosso-labio-laryngeal  Paralysis.) 

Definition. — Paralysis  of  the  lips,  tongue,  pharynx,  and 
larynx  from  destruction  of  the  ganglionic  cells  of  the  medulla 
oblongata. 

Etiology. — An  acute  form  is  observed  which  results  either 
from  hemorrhage  or  from  an  acute  poliomyelitis  of  the  medulla. 
The  chronic  form,  or  progressive  bulbar  palsy,  may  result 
from  chronic  poliomyelitis  involving  pi'imarily  the  medulla, 
or  from  the  extension  of  the  degenerative  process  in  paretic 
dementia,  amyotrophic  lateral  sc^lerosis,  progressive  muscular 
atrophy,  or  acute  ascending  paralysis  (Landry's  disease). 

Symptoms. — ImjDairment  of  speech ;  inability  to  protrude 
the  tongue;  dribbling  of  saliva;  difficult  swallowing;  choking 
spells  from  the  entrance  of  food  or  mucus  into  the  larynx  ; 
partial  suppression  of  the  voice  and  measured  speaking ; 
fibrillary  tremors  of  the  lips  and  tongue ;  loss  of  reflex  action  ; 


ACUTE    ASCENDING    PARALYSIS.  387 

atrophy  of  the  lips,  tongue,  and  pharynx  ;  and,  finally,  difficult 
respiration  and  disturbed  cardiac  rliythm. 

Prognosis. — Unfavorable.  The  acute  variety  is  speedily 
fatal ;  the  chronic  form  may  last  several  years.  Death  may 
result  from  exhaustion,  cardiac  failure,  or  aspiration-pneu- 
monia. 

Treatment.  —  Electricity,  strychnine,  and  the  use  of  a 
stomach-tube  when  swallowing  becomes  difficult. 

ACUTE  ASCENDING  PARALYSIS. 

(Landry's  Disease.) 

Definition. — An  acute  disease  of  rare  occurrence,  char- 
acterized by  motor  paralysis,  beginning  in  the  feet  and  rapidly 
spreading  until  it  involves  the  muscles  of  respiration  and  deg- 
lutition. 

Etiology. — The  causes  are  unknown.  It  is  usually  ob- 
served in  young  male  adults.  The  abrupt  onset,  acute  course, 
and  absence  of  known  cause  and  of  definite  lesions  have  sug- 
gested an  infectious  origin. 

Pathology. — No  demonstrable  lesions  have  been  discovered. 

Symptoms. — Febrile  symptoms  usually  usher  in  the  attack. 
The  paralysis  begins  in  the  legs  and  involves  successively  the 
trunk,  upper  extremities,  and  muscles  of  respiration  and  deg- 
lutition. The  reflexes  are  abolished.  The  sphincters  are 
retentive ;  sensation  is  usually  normal,  but  there  may  be 
parsesthesia  or  some  ansesthesia  ;  the  muscles  are  relaxed,  but 
do  not  waste  or  yield  the  reactions  of  degeneration.  In  some 
instances  the  spleen  and  lymphatic  glands  are  swollen. 

Diagnosis.  Acute  Myelitis. — Ansesthesia,  wasting,  reactions 
of  degeneration,  and  early  involvement  of  the  sphincters  will 
serve  to  distinguish  myelitis  from  acute  ascending  paralysis. 

Multiple  neuritis  will  be  separated  from  Landry's  disease  by 
the  marked  sensory  disturbances  in  the  former. 

Prognosis. — Unfavorable.  The  vast  majority  of  cases  ter- 
minate fatally  in  the  course  of  a  few  days.  Occasionally  there 
is  a  spontaneous  arrest,  and  a  gradual  restoration  to  health. 

Treatment. — Cups  to  the  spine  and  electricity  to  the 
affected  muscles  have  been  employed  with  indifferent  results. 


388  DISEASES    OF    THE    NERVOUS   SYSTEM. 


CAISSON  DISEASE. 

(Divers'   Paralysis.) 

Definition. — A  condition  observed  in  divers  and  others 
subjected  to  increased  atmospheric  pressure,  and  characterized 
by  motor  and  sensory  paralysis  and  other  nervous  symp- 
toms. 

Etiology. — A  pressure  of  more  than  two  atmospheres  is 
required  to  produce  the  paralysis,  and  the  time  elapsing  before 
its  appearance  lessens  as  the  pressure  increases. 

Pathology. — The  symptoms  have  been  ascribed  by  some 
to  the  liberation  in  the  cord  of  gases  which  have  been  absorbed 
by  the  blood  during  exposure  to  the  high  pressure ;  by  others, 
to  stasis  of  blood  and  oedema.  The  cord  is  found  congested 
and  sometimes  the  seat  of  hemorrhages. 

Symptoms. — The  condition  may  manifest  itself  immediately 
on  reaching  the  surface  or  after  the  lapse  of  several  hours. 
The  most  important  phenomena  are  pains  in  the  joints  fol- 
lowed by  motor  and  sensory  paralysis  in  the  lower  extremities. 
The  bladder  and  rectum  are  sometimes  involved.  Occasion- 
ally the  paralysis  takes  the  form  of  a  hemiplegia  instead  of  a 
paraplegia.  Gastralgia  and  vomiting  are  common  symptoms. 
In  severe  cases  coma  develops  and  death  follows  in  a  few  hours. 
Generally,  however,  the  symptoms  gradually  subside,  and  the 
power  is  fully  restored  in  the  course  of  a  few  days  or  a  few  weeks. 

Treatment. — As  a  preventive  measure  the  transition  from 
high  to  low  pressure  should  be  accomplished  gradually. 
Marked  cases  should  be  treated  as  acute  myelitis. 

IDIOPATHIC  MUSCULAR  ATROPHY. 

(Muscular  Dystrophy,  Myopathic  Atrophy.) 

Definition. — An  atrophic  condition  of  the  muscles  de- 
veloping in  early  life  and  not  dependent  upon  any  lesion  in 
the  nervous  system. 

Etiology. — The  disease  usually  manifests  itself  before 
puberty.     It  is  more  common  in  males  than  in  females.     It 


PSEUDO-HYPERTROPHIC    PARALYSIS.  389 

Is  frequently  transmitted  from  generation  to  generation,  and 
several  members  of  the  same  family  may  be  similarly  affected. 

Pathology. — No  lesion  in  the  cord  or  nerves  is  observed. 
Gowers  regards  the  disease  as  of  developmental  origin.  Micro- 
scopic examination  of  the  muscles  reveals  atrophy  of  their  fibres 
and  an  unnatural  amount  of  fat  and  connective  tissue.  When 
the  latter  elements  are  considerably  increased,  a  pseudo-hyper- 
trophy results  (pseudo-muscular  hypertrophy). 

Symptoms. — The  muscles,  especially  those  of  the  face, 
shoulders,  thighs,  buttocks,  and  calves,  lose  power  and  waste. 
Fibrillary  twitchings  are  rarely  noted.  The  reactions  of  degen- 
eration are  absent.  In  Erb^s  juvenile  type  the  atrophy  begins 
in  the  shoulder ;  in  the  Landouzy-Dejerine  type,  in  the  face. 

Diagnosis.  Chronic  Poliomyelitis. — This  disease  develops 
later  in  life  without  marked  hereditary  tendency,  and  nearly 
always  begins  in  the  small  muscles  of  the  hands — parts  which 
are  rarely  affected  in  idiopathic  atrophy. 

Multiple  Neuritis. — Paiu,  anesthesia,  parsesthesia,  the  his- 
tory, and  the  distribution  of  the  palsy  will  suggest  neuritis. 

Prognosis. — Unfavorable.  The  disease  is  incurable,  but  of 
slow  progress. 


PSEUDO-HYPERTROPHIC  PARAL.YSIS. 

(Pseudo-muscular  Hypertrophy,  Lipomatous  Muscular  Atrophy.) 

Definition. — A  disease  of  childhood,  characterized  by 
paralysis  depending  upon  degeneration  of  the  muscles,  which, 
however,  become  enlarged  from  a  deposition  of  fat  and  con- 
nective tissue. 

Etiology. — Male  sex,  childhood,  and  an  hereditary  tend- 
ency are  the  only  known  predisposing  causes.  Several  cases 
have  frequently  been  observed  in  the  same  family. 

Pathology. — The  disease  is  allied  to  idiopathic  muscular 
atrophy,  with  which  it  is  frequently  associated.  Since  no 
lesions  are  observed  in  the  cord  or  peripheral  nerves  it  is  to  be 
regarded  as  a  primary  affection  of  the  muscles.  Microscopic 
examination  reveals  an  excessive  amount  of  fat  and  connective 


390  DISEASES    OF    THE    ^TERYOirS    SYSTEM. 

tissue  between  the  muscle-fibres,  the  latter  being  atrophied  and 
more  or  less  degenerated. 

Symptoms. — The  first  symptom  to  attract  attention  is  weak- 
ness of  the  muscles ;  the  child  is  awkward,  stumbles,  and  in 
walking  seeks  support.  As  the  paralysis  increases,  the  mus- 
cles, particularly  those  of  the  calf,  thigh,  buttock,  and  back, 
enlarge.  The  upper  extremities  are  less  frequently  affected. 
When  the  child  assumes  the  erect  posture  the  feet  are  wide 
apart,  the  belly  protrudes,  and  the  spinal  column  shows  a 
marked  curvature  with  the  convexity  forward.  The  manner 
of  rising  from  the  recumbent  position  is  characteristic :  He 
straightens  himself  either  by  grasping  the  knees,  or  by  resting 
the  hands  on  the  floor  in  front  of  him,  extending  the  legs,  and 
pushing  the  body  backwards.    The  gait  is  waddling  in  character. 

Although  the  response  of  the  muscles  to  electrical  currents  is 
less  pronounced,  the  reactions  of  degeneration  are  not  present. 
•The  knee-jerk  is  lessened  or  abolished.  There  are  no  mental 
or  sensory  disturbances. 

In  the  course  of  a  few  years,  the  paralysis  becomes  so  marked 
that  the  patient  is  unable  to  leave  his  bed ;  the  enlargement 
of  the  muscles  is  followed  by  atrophy;  and  finally  death 
results  from  some  intercurrent  disease,  or  inflammation  of  the 
lungs  induced  by  the  weakened  respu-atory  power. 

Prognosis. — Absolutely  unfavorable. 

Treatment. — Remedies  generally  prove  useless.  Graduated 
exercise,  massage,  electricity,  and  hypodermics  of  stryclmiue 
may  be  employed  with  the  hope  of  staying  the  progress  of  the 
disease. 

NEURAIiGIA. 

Definition. — Paroxysmal  pain  radiating  along  the  course 
of  a  nerve-trunk. 

Etiology. — Heredity,  female  sex,  nervous  temperament, 
excesses,  overwork,  and  nervous  exhaustion  are  general  pre- 
disposing factors.  It  is  frequently  an  expression  of  ansemia. 
It  may  result  from  the  action  of  some  toxic  agent  in  the  blood  ; 
thus  it  is  common  in  malaria,  rheumatism,  gout,  syphilis,  and 


NEURALGIA.  391 

chronic  lead-poisoning.  It  may  be  caused  by  reflex  irritation  ; 
thus  a  trifacial  neuralgia  may  depend  on  caries  of  the  teeth  or 
eye-strain.  In  some  cases  neuralgia  results  from  organic  dis- 
ease of  the  nerve-centre ;  thus  obstinate  trifacial  neuralgia 
may  be  dependent  upon  some  degeneration  or  tumor  of  the 
Gasserian  ganglion. 

Exposure  to  cold  and  wet  frequently  acts  as  an  exciting 
cause  in  suscejjtible  people. 

Pathology. — The  pathological  condition  upon  which  neu- 
ralgia depends  is  unknown.  In  many  cases,  no  doubt,  it  is  a 
manifestation  of  neuritis. 

Symptoms. — Certain  prodromes  frequently  give  warning  of 
an  approaching  attack  ;  these  are  chilliness,  depression  of  spirits, 
and  perhaps  tingling  in  the  part  to  be  aifected.  The  chief 
symptom  is  intense  pain,  which  is  usually  of  a  sharp,  stabbing 
character.  The  area  supplied  by  the  affected  nerve  is  gener- 
ally hypersesthetic,  and  palpation  detects  spots  of  exquisite 
tenderness  where  the  nerve  makes  its  exit  through  a  bony 
canal  or  fibrous  sheath ;  the  latter  have  been  termed  Valliex's 
points.  In  some  cases  the  pain  is  attended  with  severe  clonic 
or  tonic  spasms  of  the  muscles.  Inspection  of  the  part  usually 
reveals  negative  results,  but  occasionally  distinct  swelling  or 
an  outbreak  of  herpes  is  observed. 

The  attack  lasts  from  a  few  minutes  to  many  hours,  and  its 
subsidence  may  be  marked  by  the  passage  of  a  large  amount 
of  pale  urine.  The  interval  between  the  paroxysms  varies  in 
different  cases ;  it  is  frequently  several  weeks  or  months.  It 
is  noteworthy  that  the  attacks  often  recur  at  regidar  intervals. 

Trifacial  Neuralgia  {^Tic  Douloureux,  Prosopalgia.) — In  this 
variety  the  pain  involves  one  or  more  branches  of  the  trifacial 
nerve.  The  tender  points  correspond  to  the  supra-orbital, 
infra-orbital,  and  mental  foramina.  Violent  spasms  of  the 
muscles  are  frequently  observed.  In  long-standing  cases  the 
hair  on  the  affected  side  may  become  coarse  and  bleached. 
Trifacial  neuralgia  is  frequently  reflex,  being  dependent  upon 
caries  of  the  teeth,  eye-strain,  nasal  disease,  or  some  distant 
centre  of  irritation. 

Intercostal  Neuixilgia. — In  this  variety  the  pain  follows  the 
course  of  the  intercostal  nerves.     It  is  frequently  associated 


392  DISEASES   OF   THE   NERVOUS   SYSTEM. 

with  an  eruption  of  herpes  zoster.  Spots  of  tenderness  may  be 
detected  near  the  vertebral  columns,  in  the  middle  of  the  nerve, 
and  near  the  sternum.  The  frequent  dependence  of  intercostal 
neuralgia  upon  spinal  caries  or  thoracic  aneurism  must  not  be 
forgotten. 

Occipital  neuralgia  involves  the  upper  cervical  nerves.  A 
spot  of  tenderness  may  be  discovered  midway  between  the 
mastoid  process  and  tlie  upper  cervical  vertebrae.  This  form 
of  neuralgia  may  be  an  expression  of  spinal  caries. 

Sciatica  has  been  described  elsewhere. 

Diagnosis.  Neuritis. — The  continuous  pain,  the  tender- 
ness along  the  entire  nerve,  the  presence  of  paresthesia,  anaes- 
thesia, paresis,  and  wasting  will  serve  to  distinguish  neuritis 
from  neuralgia. 

The  lightning-pains  of  locomotor  ataxia  must  not  be  mis- 
taken for  neuralgia.  The  abolished  patellar  reflex,  the  loss  of 
coordination,  and  the  Argyll-Robertson  pupil  in  the  former 
will  indicate  the  diagnosis. 

Prognosis. — For  the  attack  the  prognosis  is  good  ;  for  per- 
manent cure,  it  must  be  guarded.  When  the  cause  can  be 
removed  the  prognosis  is  favorable. 

Treatment.  The  Attack. — The  patient  should  be  kept  in 
a  quiet,  cool,  well-ventilated  room.  Local  applications  are 
useful ;  hot  cloths,  stimulating  liniments,  an  ointment  of 
acouitiue,  a  small  blister,  or  a  hypodermic  injection  of  cocaine, 
chloroform,  or  morphine  and  atropine  may  be  employed.  One 
of  the  following  applications  will  prove  serviceable  : — 

l^:.  Aconitinae,  gr.  iv; 
Veratrinae,  gr.  xv; 
Glycerini,  5ij  ;■ 

Cerati,  ^vj.— M.     (Da  Costa.) 
Sig. — To  be  rubbed  over  the  parts.     Do  not  apply  to  any  abrasion 
of  the  skin. 

Or— 

^   Chloral,  hydrat., 

Pulv.  camphor.,  aa  ^ss. — M. 
Sig. — Apply  with  a  camel's  hair  brush. 

Internally,  antipyrin,  phenacetin,  cannabis  indica,  bromide  of 
potassium,  butyl  chloral,  and  exalgine  are  efficient  remedies. 


MIGRAINE,  393 

Morphia  is  sometimes  requii-ed,  but  the  danger  of  inducing  tlie 
habit  should  always  be  borne  in  mind. 

2he  Interval. — Careful  search  should  be  made  for  an  exciting 
cause,  which,-  if  found,  must  be  removed.  The  teeth,  eyes, 
nose,  gastro-intestinal  tract,  urine,  and  blood  should  be  care- 
fully examined. 

In  ansemia,  iron  and  arsenic  are  indicated ;  in  syphilis, 
iodide  of  potassium  ;  in  rheumatism,  salicylate  of  sodium  or 
iodide  of  potassium  ;  in  malaria,  quinine  and  arsenic;  in  gout 
colchicum  and  lithium;  in  lead-poisoning,  iodide  of  potassium. 

Tonics  like  iron,  quinine,  strychnine,  cod-liver  oil,  and  phos- 
phorus are  frequently  indicated.  Among  the  special  reme- 
dies may  be  mentioned  arsenic,  velerian,  hyoscyamus,  aconitia, 
gelsemium,  cannabis  indica,  oxide  of  zinc,  nitro-glycerin,  and 
asafoetida.  The  following  pill,  devised  by  Dr.  S.  D.  Gross,  is 
often  very  useful  : — 

^   Quinin,  sulph.,  gj 

Morphin.  sulph., 

Acid,  arsenosi,    aa  gr.  iss  ; 

Ext.  aconiti,  gr.  xv  ;  .     ' 

Strychnin,  sulph.,  gr.  j.— M. 
Ft.  in  pil.  IS'o.  xxx. 
Sig. — One,  thrice  daily. 

Local  treatment  in  the  interv^al  may  accomplish  much. 
Electricity,  acupuncture,  or  repeated  blisters  may  be  employed. 
In  obstinate  cases  surgical  interference  may  be  required  to 
secure  relief.  Three  operations  have  been  performed  :  Nerve- 
stretching  ;  neurotomy,  or  section  of  the  nerve ;  and  neurec- 
tomy, or  removal  of  a  portion  of  the  nerve. 

MIGRAINE. 

(Hemicrania,  Megrim,  Sick-headache.) 

Definition. — Paroxysmal  circumscribed  headache  asso- 
ciated with  visual,  vaso-motor,  and  gastric  disturbances. 

Etiology. — It  is  frequently  hereditary.  It  is  more  com- 
mon in  women  than  in  men.  It  usually  develops  in  early  life. 
Anaemia,  gastric  disturbances,  gout,  eye-strain,  menstrual 
disorders,  overwork,  and  prolonged  excitement  predispose 
to  it. 


394  DISEASES    OF   THE    NERVOUS    SYSTEM. 

Pathology. — Unknown.  There  is  a  tendency  to  regard 
it  as  an  indication  of  hereditary  degeneration. 

Symptoms. — The  attack  is  often  preceded  by  malaise,  rest- 
lessness, and  perverted  vision.  The  pain  is  sharp  and 
stabbing  and  frequently  limited  to  the  temporo-frontal  region 
of  one  side.  The  surface  is  extremely  hypersestbetic,  but  the 
tender  spots  noted  in  trifacial  neuralgia  are  absent.  The 
patient  is  very  sensitive  to  light  and  sound,  and  during  the 
attack  usually  confines  herself  to  a  darkened  room.  Nausea 
and  vomiting  are  frequently  present.  In  some  cases  the  tem- 
poral artery  is  contracted,  the  face  is  pale,  and  the  pupil  large ; 
in  others  the  artery  is  dilated,  the  face  is  flushed,  and  the 
pupil  small.  The  duration  of  the  attacks  varies  from  a  few 
hours  to  several  days.  In  the  intervals,  which  are  often  of 
definite  duration,  the  patient  may  be  quite  well. 

Less  frequent  symptoms  are  vertigo,  hallucinations  of  sight, 
cramps  of  the  facial  muscles,  tingling  or  numbness  in  one 
hand,  partial  aphasia,  and  paresis  of  the  ocular  muscles. 

Prognosis. — Perfect  cure  is  rare,  but  the  severity  and  fre- 
quency of  the  seizures  may  be  couvsiderably  lessened  by  treat- 
ment. 

Treatment.  The  Attach. — Rest  in  a  darkened,  quiet,  and 
well-ventilated  room ;  antipyrin,  caffeine,  bromide  of  potas- 
sium, salol,  and  morphine  with  atropine  are  useful  remedies. 

]^  Antipyrin,  3j  ; 

Syr.  aurant.  cort.,  f^j  ; 
Aquee,  q.  s.  ad  f.^iij. — M. 
Sig. — A  tablespoonfiil  every  two  hours. 

Or— 

^   Caffein.  citrat.,  gr.  xij  ; 

Phenacetin,  gr.  xviij  ; 

Sodii  bromid.,  3j. — M. 
Ft.  in  chart.  No.  vi. 
Sig. — One  powder  every  hour. 

Or— 

^   Salol,  3j  ; 

Caffein.  citrat., 

Phenacetin,  aagr.  xviij. — M. 
Ft.  in  chart.  No.  vi. 
Sig. — One  every  two  hours. 


HEADACHE.  395 

The  Interval. — Careful  search  should  be  made  for  some  ex- 
citing cause,  and  this  removed,  when  possible.  The  habits 
of  the  patient  must  be  regulated.  Overwork  and  the  use  of 
alcohol,  strong  tea  and  coffee  must  be  interdicted.  Systematic 
exercise  and  frequent  bathing  followed  by  friction  are  valuable 
adjuncts.  The  diet  must  be  adapted  to  the  condition  of  the 
stomach  and  the  needs  of  the  system.  Internally,  arsenic, 
iodide  of  potassium,  bromide  of  potassium,  valerianate  of  zinc, 
and  cannabis  indica  are  the  most  reliable  remedies.  Cannabis 
indica  is  often  very  efficient,  and  a  quarter  to  half  a  grain  of 
the  extract  may  be  given  for  a  prolonged  period.  Little 
recommends  : — 

^  Soclii    arsenat.,   gr.  ij  ; 

Ext.  cannabis  indicee,  ^v.  iv  ; 
Ext.  belladonnae,  gr.  viij.— M. 
Ft.  in  pil.    No.  xxiv. 
Sig. — One,  twice  daily. 

HEADACHE. 

(Cephalalgia.) 

Definition. — Pain  in  the  head  generally  resulting  from  a 
disturbance  of  the  cerebral  circulation,  a  perverted  condition 
of  the  blood,  reflex  irritation,  or  pressure  on  the  brain  by  in- 
flammatory exudate,  depressed  bone,  or  a  tumor. 

Organic  Headache. — This  form  is  observed  in  meningitis, 
cerebral  tumor,  abscess,  softening,  etc.,  and  may  be  recognized 
by  its  persistence  and  by  the  associated  evidences  of  organic 
cerebral  disease,  such  as  optic  neuritis,  mental  aberration, 
paralysis,  especially  of  the  facial  muscles,  and  vomiting 
arising  independently  of  other  gastric  symptoms. 

Under  this  head  is  included  the  headache  of  syphilis,  which 
may  be  diagnosed  by  the  history  ;  by  the  other  evidences  of 
syphilis ;  by  its  frequent  association  with  somnolence  ;  and 
by  the  effect  of  iodide  of  potassium. 

Headache  of  Cerebral  Hypersemia. — Active  cerebral  con- 
gestion usually  results  from  prolonged  mental  work,  fever, 
or  exposure  to  the  sun.  Toxic  and  reflex  headaches  are  often 
directly  due  to  active  cerebral  congestion,  but  these  will  be 
discussed  later. 


396  DISEASES    OF    THE   XERVOUS    SYSTEM. 

Passive  cerebral  congestion  may  result  fi'om  obstruction  to 
the  return  of  blood  from  the  brain,  as  by  a  tumor  of  the  neck, 
or  cardiac  disease.  It  is  also  common  in  elderly  people  from 
a  relaxed  condition  of  the  vessels. 

In  cerebral  congestion  the  headache  is  of  a  throbbing  or 
bursting  character ;  the  head  is  hot ;  the  face  flushed ;  the 
eye-ground  injected  ;  and  the  distress  is  increased  by  lowering 
the  head. 

The  exciting  cause  must  be  determined  by  the  history  and 
by  a  careful  examination  of  the  various  organs,  especially  the 
heart. 

Headache  of  Cerebral  Ansemia.— This  is  frequently  de- 
pendent upon  general  anaemia.  It  is  also  common  in  neuras- 
thenia resulting  from  overwork,  prolonged  emotional  excite- 
ment, excesses,  etc.  More  rarely  it  is  dependent  upon  aortic 
stenosis. 

In  cerebral  ansemia  the  pain  is  frequently  vertical ;  it  is  not 
throbbing,  but  it  is  described  as  a  sensation  of  weight  or  gnaw- 
ing ;  the  extremities  are  cold  ;  the  face  and  eye-grounds  are 
pale ;  the  mind  is  depressed ;  fainting  spells  are  often  present ; 
lowering  the  head  and  the  inhalation  of  nitrite  of  amyl  relieve 
the  pain. 

Reflex  Headache. — Headache  is  often  due  to  eye-strain  re- 
sulting from  refraction  errors,  and  in  obstinate  cases  a  careful 
examination  of  the  eyes  should  always  be  made.  Headache 
of  this  origin  is  frequently  a  browache,  and  may  be  associated 
with  restlessness,  vomiting,  and  insomnia.  It  is  induced,  or 
aggravated  by  prolonged  use  of  the  eyes. 

Ovarian  or  uterine  diseases  often  produce  a  reflex  headache. 
It  is  usually  located  at  the  vertex,  and  is  relieved  by  pressure 
of  the  hand. 

Gastric  irritation  is  responsible  for  many  headaches ;  the 
latter  are  invariably  relieved  by  vomiting,  and  are  usually 
associated  with  other  evidences  of  stomachic  disorder. 

Nasal  catarrh  may  induce  persistent  headache,  which  is 
generally  confined  to  the  forehead,  temples,  or  vertex,  and  is 
aggravated  by  exacerbations  of  the  catarrah.  Tlie  pain  is 
often  associated  with  tenderness  of  the  inner  wall  of  the  orbit, 


HEADACHE.  397 

and  is  increased  by  irritating  the  nasal  mucous  membrane 
with  a  probe. 

Toxaemic  Headache. — A  persistent  headache  often  results 
from  Bright's  disease,  and  is  urcemic  in  origin.  It  may  be 
recognized  by  the  high  arterial  tension  and  by  the  albumin 
and  casts  in  the  urine.  A  urinary  analysis  should  be  made  in 
all  cases  of  persistent  headache. 

Gout  or  lithcemia  produces  an  intractable  headache  which  is 
associated  with  vertigo,  great  irritability  of  temper,  and  a 
"brick-dust"  deposit  in  the  urine. 

Chronic  malarial  poisoning  may  manifest  itself  in  a  head- 
ache which  is  usually  confined  to  the  supraorbital  region.  It 
is  apt  to  recur  at  regular  intervals,  is  often  associated  with 
tenderness  over  the  supraorbital  nerve,  and  is  only  relieved 
by  large  doses  of  quinine. 

A  headache  of  rheumatio  origin  sometimes  develops  in  those 
subject  to  rheumatism.  It  is  frequently  excited  by  exposure 
or  a  sudden  change  of  temperature.  It  usually  affects  the 
aponeurosis  of  the  occipito-frontalis  and  temporal  muscles,  is 
increased  by  wrinkling  the  forehead  and  forcibly  moving  the 
jaws,  aud  is  associated  with  tenderness  of  the  scalp. 

Alcoholism  is  often  associated  with  headache.  In  acute 
alcoholism,  the  headache  probably  results  from  cerebral  hyper- 
semia  ;  in  chronic  alcoholism  it  is  often  due  to  a  low  grade  of 
meningitis. 

Among  other  headaches  of  toxic  origin  may  be  mentioned 
those  due  to  constipation,  lead-poisoning,  diabetes,  infectious 
fevers,  and  absorption  of  foul  gases. 

Hysterical  Headache. — In  hysteria  there  is  often  a  per- 
sistent headache,  which  grows  worse  at  the  menstrual  periods, 
and  which  improves  under  pleasurable  excitement.  It  may  be 
diffuse,  but  frequently  it  is  localized,  and  is  described  as 
resembling  the  effect  which  would  be  produced  by  a  nail  being 
driven  into  the  head ;  hence  it  has  been  termed  clavus. 

Diagnosis. — Headache  must  be  distinguished  from  mi- 
graine. In  the  latter  there  are  usually  prodromal  symptoms, 
disturbances  of  vision,  pupillary  changes,  and  the  pain  is  fre- 
quently confined  to  one  side  of  the  head. 

Headache  in  the  region  of  the  orbit  may  be  mistaken  for 


398  DISEASES    OF    THE    NERVOUS    SYSTEM. 

acute  glaucoma,  but  in  the  latter  condition  the  eye  is  inflamed  ; 
the  cornea  is  hazy ;  the  pupil  is  sluggish ;  vision  is  impaired  ; 
and  on  palpation  the  affected  eyeball  is  found  to  be  harder 
than  its  fellow. 

Treatment. — In  the  interval  between  the  attacks  careful 
search  should  be  made  for  the  cause,  which,  if  possible,  must 
be  removed.  In  the  reflex  headache  of  eye-strain  the  ad- 
justment of  proper  glasses  is  often  all  that  is  required.  In 
gastric  headache,  the  associated  catarrh  of  the  stomach  must  be 
treated  by  a  light  diet  and  the  use  of  such  remedies  as  bismuth 
and  nitrate  of  silver.  In  the  headache  of  anaemia,  a  nutritious 
diet,  with  iron,  arsenic,  and  other  tonics  will  be  required.  In 
headaches  of  ursemic  origin,  a  milk  diet  with  measures  cal- 
culated to  increase  the  action  of  the  skin,  bowels,  and  kidneys, 
will  often  afford  considerable  relief  In  malarial  headache 
.quinine  in  large  doses  with  arsenic  will  effect  a  cure. 

The  Attack. — In  headache  dependent  upon  gastric  acidity, 
after  unloading  the  stomach  with  a  non-irritating  emetic, 
bromides  with  antacids  will  prove  useful,  thus  : — 

]^   Sodii  bromid.,3ij  ; 

Spt.  amnion,  aromat.,  f^ij  ; 
Aquse  q.  s.  ad  f^iij. — M. 
Sig. — A  tablespoonful  every  hour  or  two. 

In  headache  of  acute  cerebral  congestion  the  feet  should  be 
soaked  for  ten  or  fifteen  minutes  in  very  hot  water ;  an  ice- 
bag  placed  on  the  head  ;  and  some  sedative  like  the  following 
administered  : — 

]^  Phenacetin,  2;j  ; 

Sodii  bromid.,  ^ss. — M. 
Ft.  in  chart  'No.  xii. 
Sig. — One  powder  every  liour  or  two  until  relieved. 

When  the  attack  is  very  severe,  aconite  (gtt.  j-ij)  may  be 
given  every  hour  or  two. 

In  cerebral  ansemia  good  temporarily  follows  the  use  of 
antipyrin  or  phenacetin,  especially  in  combination  with  caffeine, 
thus : — 

'^   Phenacetin,  3j  ; 

Caffein.  citrat.,  gr.  xxiv. — M. 
Ft.  in  chart  No.  xii. 
Sig. — One  as  required. 


NEURITIS.  3{)9 

In  rheumatic  headache  salol  is  very  useful ;  it  may  be  com- 
bined with  antipyrin  : — 

^   Salol,  5SS  ; 

Antipyrin,  ^j. — M. 
Et.  in  chart  Ko.  x. 
Sig. — One  every  hour  or  two  until  relieved. 

In  ursemic  headache  the  diet  should  be  restricted  to  milk, 
action  of  the  bowels  secured  by  a  saline  draught,  and  diuresis 
encouraged  by  digitalis,  caffeine,  or  the  vegetable  salts  of  po- 
tassium : — 

^  Potass,  citrat.,  ^ij  ; 
Spt.  juuiperi,  fgvj  ; 
^ther.  nitros.,  f^ij  ; 
Infus.  scoparii,  f|vj. — M.     (Day.) 
A  wineglassful,  thrice  daily. 

]VEURITIS. 

Definition, — Inflammation  of  nerves. 

Etiology. — (1)  It  may  result  from  traumatism — blows, 
M^ounds,  or  compressiou.  (2)  It  may  be  due  to  exposure  to 
cold  and  wet.  (3)  It  may  be  secondary  to  inflammation  of 
adjacent  structures.  (4)  It  may  be  secondary  to  rheumatism, 
gout,  syphilis,  or  one  of  the  infectious  fevers. 

Pathology. — The  sheath,  interstitial  connective  tissue,  or 
fibres  may  be  independently  affected,  but  as  a  rule,  all  parts  of 
the  nerve  are  involved.  When  the  process  is  acute  the  nerve 
is  red  and  swollen,  and  microscopic  examination  reveals  an 
infiltration  of  leucocytes,  with  more  or  less  granular  degenera- 
tion of  the  fibres. 

In  chroniG  neuritis  the  nerve-trunk  is  gray,  shrivelled,  and 
hard,  and  microscopic  examination  shows  an  overgrowth  of 
connective  tissue  and  granular  degeneration  of  fibres. 

Symptoms  op  Acute  Neuritis. — There  are  three  sets  of 
phenomena — sensory,  motor,  and  trophic. 

Sensory  Symptmns.  —  There  is  severe  pain  following  the 
course  of  the  affected  nerve,  which  is  tender  to  the  touch.  The 
pain  is  often  associated  with  various  manifestations  of  parse.s- 


400  DISEASES    OF    THE    ^'ERVO^S    SYSTEJNf. 

thesia,  such  as  burning,  numbness,  tingling,  and  the  like.  The 
jjart  is  at  first  hypersesthetic,  but  later  it  is  more  or  less  anses- 
thetic. 

Motor  Symptoms. — Muscular  power  is  impaired  ;  there  may 
be  fibrillar  tremors ;  and  the  reflexes  are  diminished  or  lost. 

Trophic  Symptoms. — An  eruption  of  herpes  sometimes  fal- 
lows the  aiFected  nerves.  The  skin  may  become  glossy  and 
the  nails  lustreless  and  brittle.  In  advanced  cases  there  art- 
wasting  of  muscles  and  impaired  electro-contractility.  Occa- 
sionally effusion  into  the  joints  is  observed. 

lu  some  cases  there  may  be  febrile  symptoms. 

Chronic  neuritis  is  characterized  by  pain,  anaesthesia,  paresis, 
atrophy  and  contracture  of  the  muscles,,  reactions  of  degen- 
eration, "  glossy  skin,"  and  thickening  and  brittleness  of  the 
nails. 

Diagnosis. — Neuritis  may  be  mistaken  for  neuralgia  ;  but 
in  the  latter  the  pain  is  paroxysmal  and  is  uuassociated  with 
tenderness  along  the  course  of  the  nerve,  parsesthesia,  anaes- 
thesia, paresis,  and  changes  in  the  electro-contractility. 

Peognosis. — In  acute  cases  the  prognosis  is  guardedly 
favorable ;  the  duration  is  from  a  few  days  to  several  weeks. 
In  chronic  neuritis,  after  the  development  of  marked  trophic 
changes,  the  prognosis  is  grave. 

Treatment. — The  cause  should  be  ascertained  and,  if  pos- 
sible, removed.  In  rheumatism,  alkalies  and  salicylates  are 
indicated.  In  syphilis,  iodide  of  potassium  should  be  admin- 
istered in  large  doses.  The  part  should  be  put  at  rest. 
For  the  pain,  sedative  lotions  (lead-water  and  laudanum), 
warm  fomentations,  or  small  blisters  may  be  applied  to  the 
affected  parts,  and  morphine  administered  hypodermically. 
When  morphiue  is  contraindicated,  salicylate  of  sodium  or 
phenacetiu  may  be  employed  in  its  stead.  After  the  sub- 
sidence of  acute  symptoms,  iodide  of  potassium  may  be  given 
for  its  absorbent  effect  and  small  blisters  applied  locally. 
Restoration  of  power  wall  be  assisted  by  massage  and  elec- 
tricity, and  by  the  administration  of  strychnine,  internally  or 
hypodermically. 


MULTIPLE    NEURITIS.  401 

MULTIPLE  NEURITIS. 

Definition. — Inflammation  of  several  nerve-trunks,  re- 
sulting from  a  general  cause,  and  characterized  by  pain, 
pareesthesia,  anaesthesia,  paresis,  and  muscular  atrophy. 

Etiology. — Alcoholism,  syphilis,  rheumatism,  the  infec- 
tious fevers,  exposure  to  cold  and  wet,  and  mineral  })oisoning 
are  common  causes.  In  the  Orient,  multiple  neuritis  occurs 
as  an  endemic  disease  (Kakke  or  Beri-beri),  which  is  probably 
microbic  in  origin. 

Symptoms. — The  acute  form  is  characterized  by  a  chill  fol- 
lowed by  moderate  fever  (102°-103°),  headache,  pain  in  the 
back,  malaise,  coated  tongue,  loss  of  appetite,  constipation, 
febrile  urine,  and  the  following  local  phenomena  :  Pain,  numb- 
ness, and  tingling  in  the  affected  limbs;  loss  of  power,  espe- 
cially in  the  legs  and  extensor  muscles ;  abolition  of  the 
reflexes ;  atrophy  of  the  muscles ;  more  or  less  ansesthesia ; 
and  tenderness  over  the  nerve-trunks. 

Chronic  Form. — Febrile  symptoms  are  absent  and  the  di,:,- 
ease  is  manifested  by  pains  in  the  limbs,  hyperesthesia,  paraes- 
thesia,  irregular  areas  of  ansesthesia,  loss  of  power,  abolition 
of  the  deep  reflexes,  tenderness  over  the  nerve-trunks,  wasting 
of  the  muscles,  impaired  electrical  contractility,  and  oedema  of 
the  hands  and  feet. 

Complications. — Deliri'im,  delusions,  and  hallucinations 
are  not  uncomm<:'n,  especially  in  the  alcoholic  variety.  The 
disease  is  sometimes  associated  with  locomotor  ataxia. 

Diagnosis.  Locomotor  Ataxia. — The  absence  of  the  light- 
ning-pains, girdle  sensation,  Argyll-Robertson  pupil,  and  the 
presence  of  paralysis,  wasting,  and  neural  tenderness  will  serve 
to  distinguish  multiple  neuritis  from  locomotor  ataxia. 

Prognosis. — Guardedly  favorable.  Acute  neuritis  some- 
times proves  fatal  from  involvement  of  the  respiratory  mus- 
cles. In  chronic  cases  of  long  duration  the  outlook  is  not 
hopeful. 

Treatment. — Acute  cases  should  be  kept  at  absolute  rest. 
For  the  relief  of  pain  hot  fomentations,  lead-water  and  lauda- 
num, and  rubefacient  liniments  may  be  applied  to  the  affected 
limbs ;  and  morphine,  antipvrin,  phenacetin,  or  salicylic  acid 
26 


402  DISEASES    OF    THE    NERVOUS    SYSTEM. 

administered  internally.  After  acute  symptoms  have  sub- 
sided, massage,  electricity,  and  Swedish  movements  should  be 
employed  to  secure  a  return  of  power.  An  ointment  of 
mercury  and  belladonna  may  be  used  for  its  absorbent  and 
anodyne  effect.  Strychnine  hypodermically  is  an  invaluable 
muscular  tonic.  Rigidity  is  best  relieved  by  manipulation 
and  the  frequent  use  of  warm  baths.  In  syphilitic  cases  em- 
ploy mercurial  inunctions  and  iodide  of  potassium. 

SCIATICA. 

Definition. — Pain  along  the  sciatic  nerve,  usually  resulting 
from  neuritis. 

Etiology. — Male  sex,  middle  life,  gout,  rheumatism,  and 
syphilis  are  predisposing  causes.  Exposure  to  cold  and  wet 
is  the  common  exciting  cause.  Very  rarely  sciatica  is  a  sec- 
ondary condition  resulting  from  the  presence  of  an  intra-pelvic 
growth  or  from  caries  of  the  bone  in  joint  disease. 

Symptoms. — The  disease  may  begin  abruptly  or  gradually, 
aiid  is  characterized  by  a  sharp  shooting  pain  running  down 
the  back  of  the  tliigh.  Movement  of  the  limb  intensifies  the 
sufferii>g.  The  pain  may  be  uniformly  distributed  along  the 
course  of  the  nerve,  but  not  infrequently  there  are  certain 
spots  where  it  is  more  intense.  Subjective  sensations,  such 
as  tingling  and  numbness,  are  often  noted.  The  nerve  may 
be  extremely  sensitive  to  touch.  The  symptoms  grow  worse 
at  night  and  on  the  approach  of  stormy  weather.  The  dura- 
tion of  the  attack  varies  from  a  few  days  to  several  raonth». 
In  long-standing  cases  the  muscles  become  atrophied  and  rigid. 

Diagnosis.  Coxalgia. — In  this  affection  the  pain  is  most 
marked  in  the  hip-  and  knee-joints ;  pressure  over  the  tro; 
chanter  elicits  pain  ;  and  the  nerve  is  not  tender  to  the  touch. 

Prognosis. — Recovery  follows  in  the  majority  of  cases 
when  treatment  is  instituted  early  and  is  persistently  carried 
out.  In  some  cases  relapses  occur  frequently,  and  finally  the 
pain  becomes  more  or  less  continuous. 

Treatment. — In  the  acute  stage  rest  is  essential.  Hot 
fomentations  or  linear  blisters  may  be  applied  along  the 
course  of  the  nerve.     Deep  injections  of  morphine^  antipyrin, 


FACIAL    PARALYSIS.  403 

or  cocaine  may  be  required  to  relieve  the  pain.  In  rheumatio 
cases  full  doses  of  the  salicylate  of  sodium  are  very  useful. 
In  chronic  cases  prolonged  rest  is  desirable.  Counter-irritation 
should  be  made  by  frequent  small  blisters,  by  the  actual  cautery, 
or  by  acujjuncture.  Deep  injections  along  the  course  of  the 
nerve  give  much  relief,  and  one  of  the  following  remedies  may 
be  so  employed :  morphine  and  atropine,  cocaine,  antipyrin, 
or  plain  water.  Electricity  sometimes  does  good.  Internally 
iodide  of  potassium  in  small  doses  is  useful ;  in  syphilitic 
cases  it  should  be  given  in  large  doses.  The  following  com- 
bination is  also  efficient : — 

J^^  Tinct.  aconiti  rad., 
Tinct.  colchici  sem., 
Tinct.  belladonnffi, 

Tinct.  cimicifugae,  aa  f^ij. — M.     (Metcalf.) 
Sig. — Twelve  drops  every  four  to  eight  hours. 

FACIAL.  PARALYSIS. 

(BeU's  Palsy.) 

Etiology. — Paralysis  of  one  side  of  the  face  may  result : 

(1)  From  a  tumor,  clot  or  abscess  involving  the  facial  centre 
on  the  cortex  of  the  brain  or  the  nucleus  of  the  facial  nerve ; 

(2)  from  the  pressure  of  inflammatory  exudate  on  the  nerve- 
trunk  between  the  brain  and  the  skull ;  (3)  from  paralysis  of 
the  nerve  within  the  petrous  portion  of  the  temporal  bone, 
excited  by  a  fracture,  or  by  an  extension  of  inflammation  of 
the  middle  ear ;  (4)  from  inflammation  of  the  peripheral  fila- 
ments, excited  by  exposure,  injury,  rheumatism,  or  one  of  the 
infectious  fevers. 

Symptoms. — The  side  aflected  is  expressionless  ;  the  natural 
lines  are  obliterated  ;  the  angle  of  the  mouth  droops  ;  the  eye 
cannot  be  closed  ;  tears  flow  over  the  cheek  ;  and  speech  is 
aff*ected  from  an  inability  to  pronounce  the  labials.  When 
the  patient  attempts  to  laugh  or  whistle,  the  absence  of  move- 
ment on  the  affected  side  becomes  still  more  conspicuous.  In 
peripheral  neuritis  the  reflexes  are  abolished  ;  and  when  the 
nerve  is  involved  in  the  temporal  bone  there  may  be  a  loss  of 
taste  in  the  anterior  part  of  the  tongue. 


404  DISEASES    OF    THE    NERVOUS    SYSTEM. 

Diagnosis. — ^When  the  lesion  is  in  the  brain  the  paralysis 
is  rarely  complete,  the  upper  part  of  the  face  usually  escaping : 
neighboring  cranial  nerves  are  frequently  affected ;  and  other 
evidences  of  organic  brain  disease  are  generally  present. 

"When  the  nerve  is  involved  within  the  Fallopian  canal 
there  is  often  a  loss  of  taste  in  the  anterior  part  of  the  tongue, 
and  some  disturbance  of  hearing — deafness  or  perhaps  hyper- 
sensitiveness  to  sound. 

In  peripheral  neuritis  the  history,  the  completeness  of  the 
paralysis,  the  absence  of  reflexes,  and  the  presence  of  the 
reactions  of  degeneration  will  assist  in  the  recognition  of  the 
lesion. 

Prognosis. — The  prognosis  will  vary  with  the  cause.  It 
should  be  guardedly  favorable  when  the  paralysis  is  due  to 
peripheral  neuritis. 

Treatment. — The  cause  should  be  ascertained,  and  if  pos- 
sible, removed.  In  paralysis  of  centric  origin  little  can  be 
done,  except  in  syphilitic  cases.  In  middle-ear  disease  reme- 
dies should  be  directed  to  that  organ,  When  paralysis  results 
from  inflammation  of  the  peripheral  filaments  of  the  facial 
nerve,  blisters  should  be  applied  near  the  stylo-mastoid  fora- 
men, and  as  it  often  appears  to  be  an  expression  of  rheumatism, 
salicylates  may  be  given  internally.  Later,  a  course  of  iodide 
of  potassium  will  be  useful,  and  restoration  of  power  may  be 
materially  assisted  by  massage,  electricity,  and  local  injections 
of  strychnine. 

EPILEPSY. 

(Idiopathic  EpUepsy,  Falling  Sickness.) 

Definition. — A  chronic  disease  of  the  nervous  system, 
characterized  by  paroxysms  of  unconsciousness  which  are 
usually  associated  with  general  convulsions. 

Etiology. — Heredity  predisposes,  and  the  ancestral  disease 
may  not  have  been  epilepsy  but  insanity,  hysteria,  or  another 
neurosis.  It  generally  begins  before  puberty,  and  very  rarely 
after  the  twenty-fifth  year.  All  causes  which  impair  the 
health  and  exhaust  the  nervous  system  exert  a  predisposing 
influence.  The  reflex  convulsions  of  children  resulting  from 
gastric  irritation,  worms,  etc.,  if  long  continued  may  induce 


EPILEPSY.  405 

chronic  epilepsy.  In  these  cases,  although  the  exciting  cause 
has  been  removed,  the  habit  of  spontaneous  motor  discharge, 
through  constant  repetition,  is  established,  and  may  continue 
through  life.  In  those  subject  to  convulsions,  overwork,  gas- 
tric irritation,  or  excitement  may  precipitate  an  attack. 

Pathology. — No  demonstrable  causal  lesions  are  detected. 
The  disease  apparently  depends  upon  an  instability  of  the  motor 
centres,  so  that  from  trivial  exciting  causes  violent  discharges 
occur  from  time  to  time. 

Symptoms.  Grand  Mai. — The  seizure  is  often  preceded  by 
a  peculiar  sensation  termed  an  aura,  beginning  in  a  finger  or 
toe  and  rising  until  it  involves  the  head,  when  the  patient  gives 
a  shrill  scream  and  falls  to  the  floor  unconscious.  At  first  the 
face  is  pale,  the  pupils  contracted,  and  the  body  thrown  into  a 
tonic  spasm  in  which  the  head  is  retracted  and  rotated,  the 
limbs  forcibly  extended,  and  the  thumbs  turned  into  the  palms 
and  firmly  clenched  by  the  flexed  fingers.  In  a  ^q\y  seconds 
the  tonic  spasm  relaxes,  the  movements  become  clonic  or 
intermittent,  the  pupils  dilated,  the  face  cyanosed,  and  from 
the  violent  contraction  of  the  masseters  frothy  saliva,  often 
blood-streaked,  pours  from  the  mouth.  The  clonic  spasms 
continue  for  a  minute  or  two,  and  are  generally  followed  by  a 
period  of  coma  lasting  from  a  few  minutes  to  several  hours. 
Sometimes  the  patient  returns  at  once  to  consciousness,  and 
complains  simply  of  weakness,  muscular  soreness,  and  mental 
confusion.  More  rarely  the  convulsion  is  followed  by  an  out- 
break of  mania,  or  of  epileptic  automatism,  a  condition  in 
which  the  patient  unconsciously  performs  simple  or  com- 
plicated acts. 

Petit  3Ial. — In  this  type  the  seizure  consists  of  momentary 
unconsciousness,  with  pallor,  and  rarely  twitching  of  the 
muscles.  The  patient  suddenly  stops  in  the  midst  of  his  work 
or  conversation,  remains  quiet  for  a  few  seconds,  and  then  con- 
tinues where  he  left  off,  perhaps  unconscious  of  the  interrup- 
tion. Petit  mal  may  be  a  forerimner  of  gnutd  mal  or  may  alter- 
nate with  it. 

Between  these  two  extremes,  the  seizures  manifest  all  grades 
of  severity.  The  frequency  of  the  paroxysms  varies  consider- 
ably ;  they  may  occur  as  seldom  as  once  a  year,  or  as  often  as 


406  DISEASES    OF    THE    NERVOUS    SYSTEM. 

ten  or  twelve  times  a  day.  A  marked  periodicity  iu  their  re- 
currence is  often  observed. 

The  term  "  status  epilepticus"  is  applied  to  a  series  of  con- 
vulsions which  follow  each  other  in  rapid  succession,  and 
which  are  associated  with  high  fever. 

The  epileptic  may  manifest  no  other  symptoms  beyond  the 
convulsions,  but  M^hen  the  latter  are  very  frequent  the  health 
fails  and  the  mental  power  deteriorates. 

Diagnosis. — The  convulsions  of  idiopathic  epilepsy  must 
be  distinguished  from  those  due  to  organio  brain  disease  (organic 
epilepsy).  The  latter  affection  rarely  develops  before  twenty- 
five  ;  the  aura  may  be  connected  with  the  special  senses,  which 
is  uncommon  in  idiopathic  epilepsy ;  the  convulsion  is  often 
confined  to  one  member  or  to  one  side  of  the  body,  and  may 
not  be  associated  with  unconsciousness  (Jacksonian  epilepsy) ; 
the  convulsion  may  begin  in  one  member  and  then  become 
generalized ;  and  finally,  in  a  large  proportion  of  the  cases  of 
organic  epilepsy,  there  will  be  a  history  or  concomitant  symp- 
toms of  syphilis,  or  the  evidence  of  cerebral  injury. 

Urcemia. — Ursemic  convulsions  may  be  recognized  by  the 
history  and  the  results  of  the  urinary  analysis. 

Prognosis. — Generally  unfavourable.  Arrest  of  the  dis- 
ease is  rare,  but  amelioration  is  often  secured  by  treatment. 

Treatment.  Pi-eventive. — Careful  search  should  be  made 
for  the  cause  which  excites  the  paroxysms ;  this  will  often  be 
found  in  some  disturbance  of  the  gastro-intestinal  tract.  The 
diet  should  be  light,  and  as  a  rule,  largely  vegetable.  Con- 
stipation must  be  relieved  by  diet,  exercise,  or  the  use  of  mild 
laxatives.  Undue  mental  and  physical  excitement  should  be 
avoided.  Systematic  exercise  and  frequent  bathing  followed 
by  friction  of  the  skin  lessen  the  sensitiveness  of  the  nervous 
system.  The  most  reliable  drugs  are  the  bromides ;  one  or 
two  drachms  of  a  combination  of  the  bromides  of  sodium, 
potassium,  and  ammonium  may  be  given  daily.  Strontium  bro- 
mide is  often  efficacious,  and  it  is  less  depressing  than  the  other 
bromides.  The  tendency  to  acne  may  be  considerably  lessened 
by  the  addition  of  a  drop  or  two  of  Fowler's  solution  with  each 
dose.  A  small  amount  of  antipyrin  often  lessens  the  amount 
of  the  bromide  required  to  check  the  convulsions. 


APHASIA.  407 

^  Atamon.  bromid.,  gvj  ; 
*  Antipyrin,  gj  ; 
Liq.  potass,  arsenitis,  f^j  ; 
Aq.  menthee  pip.,  q.  s.  ad  fgvj. — M.     (WoOD.) 
Sig. — Tablespoonful  ia  water  night  and  morning. 

When  the  bronoides  fail,  one  of  the  following  remedies  may 
be  employed :  oxide  of  zinc  (gr.  vj-xv  a  day),  picrotoxin  (gr. 
Y^-g-  thrice  daily),  sulphonal,  borax,  or  belladonna. 

When  an  aura  gives  warning  of  a  seizure,  the  inhalation  of 
nitrite  of  amyl  may  abort  it. 

Surgical  interference  is  indicated  in  Jacksonian  epilepsy, 
and  in  those  cases  in  which  the  convulsion  begins  in  one  mem- 
ber and  subsequently  becomes  generalized. 

2^he  Attack. — As  the  seizure  is  short,  special  treatment  is 
rarely  required.  Injury  of  the  tongue  may  be  prevented  by 
placing  a  piece  of  cork  between  the  teeth.  In  the  status  epilepti- 
cus  chloroform  or  nitrite  of  amyl  may  be  administered  by  inhala- 
tion, and  hyosciue  (gr.  y^)  or  morphme  given  hypodermically. 

APHASIA. 

Definition. — A  failure  of  word-memory ;  an  inability  to 
utter  words,  to  comprehend  them,  or  to  write  them. 

'Varieties. — Sensory  and  motor. 

Sensory  Aphasia.  Word-blindness. — Inability  to  recog- 
nize written  or  printed  words.  It  results  from  a  lesion  of 
the  angular  and  inferior  parietal  gyri  of  the  left  side. 

Word-deafness. — Inability  to  interpret  spoken  words.  The 
lesion  is  in  the  posterior  half  of  the  first  and  second  temporal 
convolutions  of  the  left  side. 

Amnesic  Aphasia  {Concept  ApAasia). — Inability  to  recall 
words.  The  lesion  is  in  the  conducting  paths  between  the 
receptive  and  emissive  centres  of  the  brain,  probably  in  the 
third  left  temporal  convolution. 

Apraxia  [Psyclnc  Blindness). — Inability  to  interpret  per- 
ceptions of  sight  (mind-blindness)  ;  of  smell  (mind-anosmia)  ; 
of  taste  (mind-age ustia) ;  of  hearing  (mind-deafness) ;  or  of 
touch  (mind-atactilia).  In  mind-blindness  the  lesion  is  in 
the  supra-marginal  and  angular  gyri. 

Motor  Aphasia.     Aphemia,  or  Ataxic  Aphasia. — Inability 


408  DISEASES    OF    THE    NERVOUS    SYSTEM. 

to  utter  words,  though  knowing  their  meaning.  The  lesion 
is  in  the  posterior  part  of  the  third  left  frontal  convolution 
(Broca's  region). 

Paraphasia  {Conduction  Aphasia). — The  misuse  of  words 
or  syllables.  It  is  due  to  defect  in  the  tracts  associating  the 
cortical  speech  centres. 

3Iotor  Agrapjhia. — Inability  to  write  words  from  a  lack  of 
muscular  coordination,  rather  than  a  loss  of  power.  It  is  fre- 
quently associated  with  hemiplegia  of  the  right  side.  The  le- 
sion is  in  the  posterior  part  of  the  mid-frontal  convolution  (?). 

Amimia. — Inability  to  express  thoughts  by  signs.  This 
condition,  which  may  be  regarded  as  a  form  of  aphasia,  may 
be  sensory  or  motor.  It  is  frequently  dependent  upon  a 
lesion  of  the  left  third  frontal  convolution. 

Paramimia. — A  misuse  of  the  signs  intended  to  convey 
thought.  It  should  be  regarded  as  a  form  of  conduction 
aphasia. 

Pathology. — The  lesions  which  produce  aphasia  are 
manifold ;  the  most  important  are  :  Tumor,  gumma,  abscess, 
depressed  fracture,  embolism,  thrombus,  or  softening  in  the 
localities  which  correspond  to  the  various  forms  of  aphasia. 
In  right-handed  subjects  the  lesion  is  on  the  left  side  of  the 
brain  ;  in  the  left-handed  it  may,  however,  be  on  the  right  side. 
Aphasia  is  not  always  due  to  organic  disease  ;  it  may  be  noted 
in  congestion  of  the  brain,  in  sudden  fright,  in  the  convales- 
cence of  fevers,  in  migraine,  after  epileptic  seizures,  and  in 
hysteria. 

Diagnosis. — Aphasia  must  be  distinguished  from  aphonia. 
The  latter  condition  is  an  inability  to  utter  sounds,  a  power 
not  lost  in  aphasia ;  moreover,  aphonia  is  generally  dependent 
upon  some  abnormality  of  the  larynx  or  of  the  nerves  leading 
thereto. 

Prognosis.  — This  depends  entirely  on  the  cause.  After 
apoplexy  the  prognosis  should  be  guarded.  In  cerebral  soft- 
ening it  is  absolutely  unfavorable.  When  aphasia  develops 
in  the  young  the  outlook  is  much  more  hopeful. 

Treatment. — The  causal  condition  will  require  attention. 
The  patient  may  be  instructed  to  speak  and  to  interpret  after 
the  manner  employed  in  teaching  the  young. 


VERTIGO.  409 

VERTIGO. 

(Dizziness,  Giddiness,  S^vimming  in  the  Head.) 

Definition. — A  sense  of  unstable  equilibrium  in  which 
the  patient  himself  or  surrounding  objects  appear  to  be  in  a 
state  of  rapid  oscillation  or  rotation.  It  is  a  symptom  of 
many  conditions. 

Etiology. — Vertigo  may  result  from  : — 

1.  Cerebral  anaemia  or  congestion.  The  dizziness  preceding 
a  fainting  fit  is  an  illustration  of  the  former,  and  that  follow- 
ing exposure  to  the  rays  of  the  sun  is  an  illustration  of  the 
latter.  Vertigo  is  often  a  pronounced  symptom  of  chronic 
cerebral  congestion  and  anaemia.  The  vertigo  of  chronic  heart 
disease  and  of  neurasthenia  is  included  under  this  head. 

2.  Reflex  irritation.  The  most  common  example  of  this 
form  is  the  vertigo  dependent  upon  gastric  disturbances.  It 
is  also  noted  in  eye-strain,  uterine  disease,  constipation,  and 
disease  of  the  internal  ear.  The  last  is  termed  labyrinthine 
vertigo,  or  Meniere's  disease,  and  has  been  described  elsewhere. 

3.  Organic  disease  of  the  brain  and  cord.  Cerebral  tumor, 
meningitis,  and  softening  are  frequently  associated  with  vertigo. 
It  is  often  quite  marked  in  cerebellar  disease.  It  may  be  a 
pronounced  symptom  in  disseminated  sclerosis  and  locomotor 
ataxia. 

4.  Toxic  substances  in  the  blood.  The  vertigo  observed  in 
lithaemia,  uraemia,  and  diabetes  is  included  under  this  head. 
When  taken  in  large  doses,  certain  drugs,  as  alcohol,  bella- 
donna, cannabis  indica,  lobelia,  and  conium,  may  produce  the 
symptom.  It  is  often  a  marked  symptom  of  chronic  lead- 
poisoning. 

5.  Epilepsy.  Vertigo  may  precede,  follow,  or  take  the 
place  of  an  epileptic  seizure. 

6.  Hysteria.  Occasionally  marked  vertiginous  attacks  are 
connected  with  hysteria. 

7.  Unknown  causes.  The  term  essential  vertigo  has  been 
applied  to  those  cases  in  which,  after  the  most  exhaustive 
study,  no  adequate  cause  can  be  ascertained.  There  is  some- 
times an  hereditary  tendency  to  this  form  of  vertigo. 

Diagnosis. — Vertigo  must  be  distinguished  from  'pepit  mal. 


410  DISEASES   OF   THE    NERVOUS   SYSTEM. 

or  minor  epilepsy.  The  history,  the  presence  of  a  definite  cause, 
and  the  absence  of  unconsciousness  and  of  convulsive  move- 
ments will  serve  to  separate  vertigo  from  epilepsy. 

The  determination  of  the  cause  of  the  vertigo  must  be 
based  upon  the  history,  the  age  at  which  it  develops,  and  a 
critical  examination  of  the  various  oi'gans. 

Prognosis. — This  will  depend  entirely  on  the  cause  ;  when 
the  latter  can  be  removed,  the  prognosis  is  favorable. 

Treatment. — This  must  be  directed  to  the  causal  condition. 

MENIERE'S  DISEASE. 

(Labyrinthine  Vertigo,   Aural  Vertigo.) 

Definition.  —  Paroxysmal  vertigo,  probably"  depending 
upon  disease  of  the  internal  ear. 

Etiology  and  Pathology.  —  The  exact  cause  of 
Meniere's  disease  is  still  undetermined.  In  some  cases,  how- 
ever, inflammatory  changes  have  been  observed  in  the  semi- 
circular canals.  Very  severe  acute  attacks  are  sometimes 
observed  in  patients  previously  healthy.  In  these  the  lesion 
is  probably  an  active  hypersemia  of,  or  a  hemorrhage  into,  the 
labyrinth.  It  is  probable  that  mild  forms  of  the  disease  can 
be  indirectly  induced  by  lesions  of  the  middle  ear. 

Symptoms. — Frequently  prodromes  precede  the  attack, 
such  as  deafness  or  earache.  These,  however,  may  be  absent, 
and  the  attacks  ushered  in  with  extreme  vertigo  and  tinnitus 
aurium.  The  latter  is  often  compared  to  the  escape  of  steam, 
the  buzz  of  an  insect,  or  the  discharge  of  a  cannon.  The  patient 
feels  as  if  he  or  surrounding  objects  were  being  whirled  vio- 
lently around,  and  in  severe  cases  the  face  is  pale  and  anxious ; 
the  surface  is  clammy  ;  there  are  nausea  and  vomiting ;  and  the 
patient  falls  unconscious. 

As  a  rule,  there  is  deafness  in  one  ear  at  least,  but  ex- 
ceptionally, hearing  may  be  quite  normal.  At  first  the 
paroxysms  may  occur  at  long  intervals,  but  as  the  disease 
advances  they  become  more  frequent  and  the  tinnitus  and 
deafness  become  more  marked. 

Diagnosis. — The  paroxysmal  vertigo,  deafness,  and  tinnitus 
aurium  are  the  diagnostic  features. 


HYSTERIA.  411 

Prognosis. — The  prognosis  should  always  be  guarded. 
Some  cases  recover  entirely,  but  in  the  majority  the  vertigi- 
nous attacks  continue  until  the  deafness  in  the  aflfected  ear 
becomes  complete. 

Treatment. — The  middle  ear  should  be  carefully  ex- 
amined, and  any  existing  disease  treated.  Severe  counter- 
irritation  by  blisters,  or  the  actual  cautery  applied  behind  the 
ear,  may  be  of  some  service.  Bromide  of  potassium  or  large 
doses  of  hydrobromic  acid  may  give  temporary  relief.  Charcot 
recommends  quinine  in  sufficient  doses  to  cause  cinchonism. 

HYSTERIA. 

Definition.  —  Hysteria  is  a  functional  disease  of  the 
nervous  system,  manifested  by  symptoms  of  the  most  varied 
character,  and  associated  with  impaired  will-power  and  in- 
creased impressionability. 

Etiology. — Females  are  especially  predisposed,  although 
it  occasionally  develops  in  males.  It  is  most  common  in 
early  adult  life.  The  chief  causal  factor  is  heredity,  the  dis- 
ease frequently  being  transmitted  through  hysterical,  epilep- 
tic, or  insane  parentage. 

Traumatism,  defective  education,  prolonged  emotional  ex- 
citement, such  as  worriment,  anxiety,  disappointment  and 
grief,  and  all  causes  which  lower  the  vitality  serve  to  excite 
it  in  susceptible  individuals. 

Pathology. — No  causal  lesions  can  be  detected  after 
death. 

Symptoms. — Tlie  various  manifestations  may  be  described 
under  three  heads:  (1)  Motor,  (2)  sensory,  and  (3)  psychical. 

Motor  Phenomena. — Paralysis  not  infrequently  results  from 
hysteria ;  it  may  take  the  form  of  a  hemiplegia,  paraplegia,  or 
monoplegia,  although  the  first  is  by  far  the  most  common. 
The  paralysis  is  generally  paroxysmal,  and  is  frequently  asso- 
ciated with  contractures  and  anaesthesia.  The  affected  muscles 
do  not  waste. 

Local  paralysis  is  also  common ;  thus  there  may  be  aphonia 
from  paralysis  of  the  vocal  cords ;  dysphagia,  from  paralysis 
of  the  oesophagus ;  and  incontinence  of  m'ine,  from  paralysis 
of  the  bladder. 


412  DISEASES    OF    THE    NERVOUS   SYSTEM. 

Convulsive  seizures  are  common  manifestations  of  hysteria, 
and  may  closely  simulate  the  paroxysms  of  true  epilepsy ;  but 
there  is  no  aura;  the  patient  usually  falls  in  a  comfortable 
place ;  consciousness  is  only  apparently  lost,  for  after  the  seiz- 
ure she  remembers  all  that  has  transpired ;  the  tongue  is  rarely 
bitten  ;  the  eyes  are  partially  closed ;  the  face  is  expressive  of 
some  emotion  ;  screaming  or  sobbing  is  of  frequent  occurrence ; 
the  movements  are  apt  to  be  tonic,  so  that  the  patient  assumes 
the  position  of  opisthotonos,  or  if  clonic,  they  are  apt  to  be 
violent  and  purposive ;  the  seizures  are  of  long  duration,  and 
may  be  continued  for  several  hours  or  days,  and  firm  pressure 
over  the  ovaries  may  exaggerate  or  re-excite  them. 

The  spasms  may  be  local ;  thus  there  may  be  retention  of 
urine,  from  spasm  of  the  bladder ;  asthma,  from  spasm  of  the 
bronchi ;  hiccough,  from  spasm  of  the  diaphragm ;  persistent 
vomiting,  from  spasm  of  the  stomach;  dysphagia,  from  spasm 
of  the  oesophagus ;  and  a  "  phantom  tumor,"  from  spasm  of 
abdominal  muscles  associated  with  flatulent  distention  of  the 
intestines. 

Among  other  motor  phenomena  may  be  mentioned  obsti- 
nate tremors,  choreiform  movements,  and  contractures  of  cer- 
tain groups  of  muscles. 

Sensory  Phenomena. — There  may  be  a  complete  loss  of  sen- 
sation in  certain  parts,  as  one  side  of  the  body.  Anaesthesia 
without  other  nervous  phenomena  is  usually  hysterical.  In 
some  cases  tactile  sensation  is  preserved  and  there  is  a  loss 
only  of  thermic  or  painful  sensations.  The  anaesthetic  part  is 
often  unusually  pale,  and  when  pricked  with  a  needle  fails  to 
bleed  (ischsemia). 

The  special  senses  maybe  involved ;  thus  there  may  be  con- 
traction of  the  field  of  vision,  complete  blindness,  loss  of  smell, 
loss  of  taste,  or  loss  of  hearing.  These  special-sense  palsies 
are  usually  transient,  and  often  alternate  with  one  another. 

Instead  of  anaesthesia,  there  may  be  hypersesthesia  or  pain. 
Severe  pain  in  the  stomach  may  simulate  gastralgia.  An  ex- 
quisitely painful  and  tender  condition  of  the  abdomen  may 
be  mistaken  for  peritonitis.  A  localized  pain  in  the  head, 
described  as  resembling  the  effect  of  a  nail  being  driven  into  it, 
is  termed  hysterical  davus.  The  joints  sometimes  become 
swollen  and  very  tender,  resembling  arthritis  (neuromimesis). 


HYSTERIA.  41;} 

Intense  j)ain  over  the  heart  may  simulate  angina  pectoris. 
The  spine  is  often  the  seat  of  hypersesthesia,  especially  in  spots, 
and  this  spinal  irritation  is  often  associated  with  pain  in  parts 
corresponding  to  the  distribution  of  nerves  which  have  their 
origin  in  the  hvpersesthetic  area. 

A  very  common  abnormal  sensation  is  the  globus  hystericus, 
i.  e.,  a  feeling  as  of  a  ball  rising  in  the  throat  and  impeding 
respiration. 

Psychical  Phenomena. —  Frequently  the  only  conspicuous 
mental  phenomenon  is  the  great  lack  of  -s^'ill-power ;  but  gen- 
erally the  patients  are  more  or  less  excitable,  highly  mercurial, 
and  easily  moved  to  laughter  or  tears.  They  frequently  mani- 
fest a  great  fondness  for  sympathy,  and  this,  in  connection  with 
their  weak  will-power  and  lowered  moral  tone,  often  leads  them 
to  feign  symptoms  ^Thich  they  really  do  not  have.  Among 
the  more  serious  mental  manifestations  may  be  mentioned 
delirium,  ecstasy,  catalepsy,  and  trance. 

Diagnosis. — The  recognition  of  hysteria  is  often  attended 
with  great  difficulty,  especially  as  it  is  frequently  associated  with 
symptoms  which  really  have  an  organic  basis.  In  making  a 
diagnosis,  the  history,  sex,  and  temperament  must  be  carefully 
considered.  The  manifestations  usually  develop  abruptly ; 
are  generally  paroxysmal ;  appear  without  obvious  cause ; 
often  subside  spontaneously  under  some  emotional  excitement ; 
rarely  lead  to  any  impairment  of  the  health  ;  and  are  usually 
associated  with  a  history  of  other  hysterical  phenomena. 

PPtOGisrosis. — As  regards  life  the  prognosis  is  good.  In 
rare  instances  death  has  followed  exhaustion  induced  by  re- 
peated convulsions  or  prolonged  fasting.  While  hysteria 
usually  ends  in  recovery,  the  duration  of  the  illness  is  a  mat- 
ter of  great  uncertainty. 

A  speedy  recovery  is  to  be  expected  in  those  cases  where 
the  hysterical  phenomena  are  connected  with  some  obvious 
cause  which  can  be  removed. 

Treatment. — Careful  search  should  be  made  for  some 
exciting  cause,  which,  if  found,  should  be  removed  when 
possible.  The  physical  condition  is  generally  reduced,  and 
careful  study  must  be  given  to  the  diet,  exercise,  amusement, 
clothing,  etc.,  with  the  view  of  improving  it.     Tonics  like 


414  DISEASES    OF    THE    NERVOUS    SYSTEM. 

iron,  arsenic,  strychnine,  hypophosphites,  cod-liver  oil,  and 
malt  are  often  indicated,  and  they  may  be  advantageously 
combined  with  such  nerve  sedatives  as  valerian,  asafoetida,  sum- 
bul,  and  the  like ;  in  the  milder  manifestations,  the  following 
pill  may  prove  useful : — 

R     Acid,  arsenosi,  gr.  J ; 

Ferri  sulph.  ex., 

Ext.  sumbul,  aa  gr.  xx ; 

Asafoetidae,  gr.  xl. — M.     (Goodell.) 
Ft.  in  pil.  Ko.  XX. 
Sig. — One  after  each  meal. 

Or— 

^  Quinin.  valerianat., 

Zinci  valerianat., 

Ferri  valerianat.,  aa  gr.  xxiv. — M. 
Ft.  in  pil.  No.  xxiv. 
Sig. — One,  thrice  daily. 

R     Auri  et  sodii  chloridi,  gr.  v ; 

Tragacanth.,  3] ', 

Sacchari,  q.  s. — M.    (Mills.) 
Ft.  in  pil.  No.  xl. 
Sig. — One  thrice  dailj^,  increased  to  three  thrice  daily. 

The  more  thoroughly  the  physician  is  able  to  inspire  con- 
fidence and  to  control  his  patient,  the  more  likely  is  he  to 
effect  a  cure.  Firmness  tempered  with  kindliness  and  en- 
sou  ragement  is  essential  to  success. 

While  hypnotism  appears  to  have  been  somewhat  useful  in 
France,  in  this  country,  although  employed  but  to  a  limited 
extent,  it  has  not  given  encouraging  results,  and  moreover,  in 
the  event  of  failure,  seems  capable  of  aggravating  the  hysteri- 
cal condition. 

In  long-continued  convulsive  seizures,  cold  water  may  be 
dashed  on  the  face  and  chest,  or  hyoscine  administered 
hypodermically.  In  obstinate  cases  an  angesthetic  should  be 
employed.  In  the  various  form  of  paralysis  electricity  is 
often  useful.  In  some  cases  static  electricity,  no  doubt  from 
the  profound  mental  effect  which  it  has  induced,  has  given 
excellent  results. 

In  aggravated  cases  the  "  rest-cure"  introduced  by  S.  Weir 
Mitchell  is  often  applicable.     It  consists  in   isolation  from 


NEURASTHENIA.  416 

sympathizing  friends  and  relatives ;  abundant  feeding,  espe- 
cially with  milk ;  and  complete  rest  of  body  and  mind  with 
passive  exercise  obtained  by  massage  and  electricity. 

NEURASTHEKEA. 

(Nervous  Prostration.) 

Definition. — A  term  applied  to  a  group  of  symptoms 
apparently  resulting  from  exhaustion  of  the  nerve-centres. 

Etioeogy. — Aji  hereditary  tendency,  prolonged  mental 
work,  or  emotional  excitement,  excesses,  defective  education, 
traumatism,  and  irregular  living  are  general  predisposing 
factors. 

Symptoms.  Cerehral  Symptoms. — Depression  of  spirits, 
indisposition,  inability  to  concentrate  the  mind  on  one  subject 
for  any  length  of  time,  insomnia,  vertigo,  headache,  irritaljility 
of  temper,  introspection,  and  morbid  fears. 

Spinal  Symptoms. — Sometimes  these  predominate,  when  the 
condition  is  termed  spinal  ii'ritation,  and  its  chief  manifesta- 
tions are :  Pain  in  the  back,  spots  of  tenderness  along  the 
spine,  weakness  of  the  extremities,  great  prostration  after 
moderate  exertion,  and  various  subjective  phenomena,  such  as 
numbness,  tingling,  formication,  and  neuralgic  pains. 

Gastro-intestinal  Symptoms. — Anorexia,  coated  tongue,  and 
constipation. 

Circulatory  Symptoms. — Palpitation,  tachycardia,  psreudo- 
angina,  cold  extremities,  and  sometimes  violent  pulsation  of 
the  aorta. 

Sexual  Symptoms. — In  females,  amenorrhoea  or  dysmenor- 
rhoea ;  in  males,  impotence  or  spermatorrhoea. 

Diagnosis. — The  diagnosis  is  rarely  difficult.  Before 
relegating  a  case  to  this  class,  care  must  be  taken  to  exclude 
organic  disease,  and  such  general  disorders  as  lithcemia  and 
ancemia. 

Hysteria. — This  affection  may  be  distinguished  by  the 
abrupt  onset,  the  intermittent  character  of  the  symptoms, 
and  the  presence  of  paralysis,  ansesthesia,  convulsions,  or  the 
globus  hystericus. 


416  DISEASES   OF  THE   NERVOUS  SYSTEM. 

Prognosis. — When  the  cause  can  be  removed  and  the 
patient  controlled,  the  prognosis  is  favorable. 

Treatment. — The  treatment  is  largely  hygienic  and  die- 
tetic, and  will  vary  considerably  in  different  cases.  Where 
there  has  been  inactivity,  regulated  physical  exercise  will  be 
of  great  value;  on  the  other  hand,  the  weak  and  anseraic  will 
require  rest.  In  the  latter  case,  the  plan  of  treatment  intro- 
duced by  S.  Weir  Mitchell,  and  known  as  the  "rest-cure,'' 
often  gives  brilliant  results.  In  all  cases  careful  attention 
must  be  given  to  the  diet,  bathing,  and  clothing,  and  the 
patient  assured  that  he  is  suffering  from  no  incurable  disease. 
Frequent  bathing  with  salt  water,  followed  by  friction  of  the 
skin,  will  often  add  to  the  general  vigor.  Tobacco  and  alco- 
hol must  be  interdicted,  and  tea  and  coffee  used  very  sparingly. 
Tonics  like  iron,  arsenic,  quinine,  strychnine,  and  phosphorus 
are  often  indicated. 

CHOREA. 

(Chorea  Minor,  St.  Vitus' s  Dance.) 

Definition. — A  nervous  affection  occurring  especially  in 
children,  and  characterized  by  irregular  movements  which  in- 
crease under  excitement  and  cease  during  sleep. 

Etiology. — Childhood  (between  five  and  fifteen),  female 
sex,  season  (spring),  nervous  temperament,  and  the  rheumatic 
diathesis  are  general  predisposing  factors.  It  sometimes  de- 
velops suddenly  after  mental  or  emotional  excitement,  such  as 
anxiety,  fear,  or  grief.  It  may  be  excited  by  reflex  irritation, 
as  an  adherent  prepuce,  intestinal  parasites,  etc.  It  not  infre- 
quently develops  in  the  course  of  pregnancy. 

Pathology, — It  is  customary  to  look  upon  chorea  as  a 
neurosis,  since  no  constant  lesions  have  been  discovered  to 
account  for  its  clinical  manifestations.  In  some  cases  endo- 
carditis, and  emboli  in  the  minute  cerebral  vessels  have  been 
discovered,  but  their  relation  to  chorea  has  not  yet  been  de- 
termined.    A  microbic  origin  has  been  suggested. 

Symptoms. — The  first  manifestations  are  usually  restlessness 
and  awkwardness  in  movement.  The  child  cannot  remain 
still,  but  is  constantly  raising  its  shoulders,  jerking  its  head, 


CHOREA.  417 

twisting  its  fingers,  or  shuffling  its  feet.  Frequently  these 
symptoms  develop  so  insidiously  that  the  disease  is  not  recog- 
nized, and  the  child  is  punished  for  being  fidgety. 

When  the  disease  is  fully  established  the  disorderly  move- 
ments become  more  marked,  and  may  be  confined  to  one 
member  or  may  involve  the  entire  body.  When  the  facial 
muscles  are  aifected,  the  most  grotesque  expressions  are  pro- 
duced ;  involvement  of  the  arms  may  interfere  with  eating 
and  dressing  •  when  the  legs  suffer  the  gait  becomes  jerking 
and  stumbling  ;  involvement  of  the  larynx  causes  stammering ; 
and  spasm  of  the  muscles  of  deglutition  induces  difficult 
swallowing  and  choking-spells.  When  the  attention  is  directed 
to  the  movements  they  invariably  grow  worse,  but  they 
dimmish  during  repose  and  cease  entirely  during  sleep. 
Sometimes,  in  addition  to  the  involuntary  movements,  there  is 
a  distinct  loss  of  power  in  the  affected  members.  The  general 
health  is  usually  more  or  less  impaired.  The  child  is  anaemic; 
the  temper  is  irritable  ;  and  the  mental  power  deficient.  Aus- 
cultation of  the  heart  often  detects  a  murmur  which  may  be 
either  an  expression  of  anaemia  or  of  complicating  endocarditis. 

In  some  cases  {chorea  insaniens)  the  movements  are  so 
violent  that  the  patient  is  unable  to  walk,  eat,  or  even  to  lie 
down.  Fever  develops,  and  ultimately  the  mind  becomes  de- 
lirious. Death  frequently  results  from  exhaustion.  This  form 
is  usually  observed  in  adults,  and  especially  in  primiparse. 

Diagnosis. — The  recognition  of  chorea  is  rarely  attended 
with  difficulty.  Disseminated  spinal  sclerosis  may  be  dis- 
tinguished by  the  presence  of  nystagmus,  a  scanning  speech, 
increased  reflexes,  and  a  rhythmical  tremor  which  is  only  ex- 
cited by  movement. 

<  Prognosis. — In  simple  chorea  recovery  usually  follows  in 
the  course  of  two  or  three  months.  Death  from  heart  com- 
plications is  a  rare  termination.  Relapses  are  not  infrequent. 
Among  the  possible  sequelae  may  be  mentioned  imbecility  and 
chronic  chorea. 

Chorea  insaniens  frequently  terminates  fatally  through  ex- 
haustion. 

'  Treatment. — Rest  of  body  and  mind  is  an  essential  ele- 
ment of  the  treatment.     The  child  should   be  taken   from 


418  DISEASES   OF   THE   NERVOUS  SYSTEM. 

school  and  placed  under  the  most  favorable  hygienic  condi- 
tions. Careful  search  should  be  made  for  reflex  irritation, 
such  as  adherent  prepuce,  intestinal  parasites,  eye-strain,  etc. 
All  excitement  must  be  avoided.  Amusement  in  the  open  air 
when  the  weather  is  fine  is  to  be  recommended.  As  the  child 
is  generally  anaemic,  iron  is  indicated  in  the  majority  of  cases. 
Among  the  special  remedies  arseuic  holds  the  first  place.  Fow- 
ler's solution  may  be  given  in  doses  of  two  drops  thrice  daily, 
gradually  increased  to  eight  or  ten  drops  thrice  daily.  Among 
other  remedies  may  be  mentioned  the  fluid  ext.  of  cimicifuga 
(iTlx  increased  to  3j  thrice  daily),  hyoscyamine  (gr.  tsq  i-g-o); 
and  quinine  (gr.  iij-v  every  two  or  three  hours). 

In  Chorea  insaniens  forced  feeding  should  be  resorted  to. 
Morphine  and  other  sedatives  may  be  employed  hypodermi- 
cally.  Chloroform  may  be  required  to  control  temporarily 
the  movements.  Severe  cases  of  chorea  complicating  preg- 
nancy will  call  for  the  induction  of  premature  labor. 

PAKALYSIS  AGITAlSrS. 

(Parkinson's  Disease,  Shaking  Palsy.) 

Definition. — A  chronic  nervous  disease,  characterized  by  a 
fine,  slowly-spreading  tremor,  muscular  weakness  and  rigidity, 
and  a  peculiar  gait,  t&v\nedi  festination. 

Etiology. — Advanced  life,  a  neuropathic  tendency,  mental 
strain,  heredity,  and  exposure  to  cold  aud  wet  are  predisposing 
factors.  It  sometimes  develops  suddenly  after  intense  mental 
or  emotional  excitement. 

Pathology. — The  pathology  is  unknown.  The  lesions 
found — degeneration  of  arterioles,  perivascular  sclerosis,  pig- 
mentation of  ganglionic  cells — are  similar  to  those  induced  by 
senility. 

Symptoms. — In  some  cases  the  onset  is  abrupt,  but  more 
commonly  the  disease  develops  insidiously.  The  first  symptom 
is  usually  a  fine  tremor  beginning  in  the  hand  or  foot,  which 
may  slowly  spread  until  it  involves  all  the  members;  the 
head  is  rarely  affected.  At  first  the  tremor  may  be  parox- 
ysmal, but  as  the  disease  advances  it  becomes  almost  continuous. 
Excitement  increases  it,  but  it  is  noteworthy  that  physical 
effort  temporarily  diminishes  or  checks  it     The  face  becomes 


PAEALYSIS   AGITANS.  419 

expressionless,  and  the  si^eech  slow  and  measured.  Later 
muscular  rigidity  develops ;  the  head  is  bowed,  the  body  bent 
forward,  the  arms  flexed,  the  thumbs  turned  into  the  palms 
and  grasped  by  the  fingers,  and  the  knees  slightly  bent.  At 
this  time  the  gait  is  characteristic :  the  ste]3S  grow  faster  and 
faster,  the  body  inclines  more  and  more  forward  until  the 
patient  falls,  seeks  support  in  some  neighboring  object,  or 
straightens  himself  by  a  supreme  effort  of  the  will.  The  term 
festination  has  been  applied  to  this  peculiar  gait.  Occasionally 
a  tendency  to  fall  backwards — retropulsion—re])laces  festina- 
tion. The  rigidity  and  muscular  weakness  render  all  move- 
ments slow  and  labored. 

Intelligence  is  usually  good.  There  is  no  anaesthesia,  but 
there  are  various  manifestations  of  parsesthesia,  such  as  numb- 
ness and  tingling ;  a  sensation  of  heat  is  especially  noted.  In 
some  cases  free  perspiration  has  been  observed. 

Diagnosis. — The  tremor,  rigidity,  weakness,  flexion  of  the 
body  and  members,  lack  of  facial  expression,  and  festination 
are  the  diagnostic  features.  In  some  cases  the  tremor  is  absent. 
Paralysis  agitans  must  be  distinguished  from  disseminated 
sclerosis.  In  th$  latter  the  tremor  is  coarse,  is  frequently  ab- 
sent when  the  patient  is  quiet,  and  is  made  worse  by  efforts  to 
control  it ;  cerebral  symptoms  are  generally  present ;  nystag- 
mus is  often  noted ;  and  the  attitude  and  gait  are  entirely 
different  from  those  of  paralysis  agitans. 

ProgjsiOSIS. — Recovery  rarely,  if  ever,  occurs.  In  some 
cases,  after  reaching  a  certain  point,  the  disease  remains  sta- 
tionary.    The  progress  is  slow  and  the  duration  indefinite. 

Teeat]\[ENT. — Measures  intended  to  improve  the  tone  of 
the  system  are  indicated  ;  these  are  :  A  regulated  diet,  rest  of 
body  and  mind,  frequent  bathing  followed  by  friction  of  the 
skin,  and  the  use  of  such  tonics  as  iron,  arsenic,  and  phos- 
phorus. The  rigidity  and  tremors  are  sometimes  improved  by 
massage  and  electricity.  Among  the  remedies  recommended 
for  the  tremors  are  bromide  of  potassium,  duboisine,  hyoscya- 
mine  (gr.  y^-q),  and  hyoscine  (gr.  yis")?  '^^ut  the  improvement 
following  their  use  is  only  slight  and  temporary. 


420  DISEASES   OF   THE   NERVOUS   SYSTEM. 

AUTISANS'  CRAMP. 

Definition. — A  spasmodic  affection  of  the  muscles  in- 
duced by  prolonged  work  requiring  delicate  coordination,  and 
occurring  only  in  the  performance  of  that  particular  work. 

Etiology. — It  is  more  common  in  men  than  in  women, 
and  the-  nervous  temperament  predisposes  to  its  development. 
The  occupations  in  which  it  is  most  apt  to  occur  are  writing, 
piano-playing,  sewing,  and  telegraphing. 

Pathology. — The  disease  is  evidently  not  peripheral,  for 
when  the  other  hand  is  substituted  the  condition  soon  develops 
in  that  member.  It  is  probably  dependent  upon  unnatural 
irritability  of  the  nerve-centres. 

Writers'  Cramp. 

(Graphospasm,  Scriveners'  Palsy.) 

Symptoms. — The  condition  usually  begins  with  a  sense  of 
fatigue,  weight,  or  actual  pain  in  the  affected  muscles.  Soon 
the  fingers  are  seized  with  a  tonic  or  clonic  spasm  whenever 
the  pen  is  grasped  (spastic  form).  In  some  cases  the  hand 
when  put  into  use  becomes  the  seat  of  a  decided  tremor 
(tremulous  form) ;  in  a  third  group  of  cases  the  chief  phe- 
nomena are  excessive  weakness  and  fatigue,  which  disappear 
as  soon  as  the  pen  is  laid  aside  (paralytic  form). 

Prognosis. — Guardedly  favorable.  The  disease  is  obsti- 
nate, but  cure  generally  follows  protracted  rest. 

Treatment. — Absolute  rest  is  the  essential  element  of 
treatment.  The  general  condition  should  be  improved  by 
iron,  arsenic,  strychnine,  and  cod-liver  oil.  Massage,  electricity, 
and  passive  movements  give  good  results. 

TETAJNT. 

(Tetanilla,  Intermittent  Tetanus.) 

Definition. — A  nervous  affection,  characterized  by  tonic 
spasms  which  are  usually  paroxysmal  and  involve  the  ex- 
tremities. 

Etiology. — It  is  most  frequently  observed  in  the  young. 
In  women  it  is  frequently  associated  with  pregnancy  or  lacta- 


thomsen's  disease.  421 

tion.  It  is  sometimes  excited  by  exposure,  emotional  excite- 
ment, or  one  of  the  infectious  fevers.  An  epidemic  form  has 
been  described,  but  some  of  the  outbreaks  seem  to  have  been 
hysterical.  A  very  grave  form  has  been  induced  by  thyroid- 
ectomy and  by  lavage  in  gastric  dilatation. 

Symptoms. — The  patient  is  seized  with  bilateral  tonic 
spasms  in  the  arms  and  legs.  The  jaws  are  rarely  involved. 
The  contractions  are  usually  paroxysmal  and  are  attended  with 
pain.  As  was  pointed  out  by  Trousseau,  they  can  be  induced 
by  pressure  over  the  arteries  and  nerves  of  the  affected  limb. 
The  electro-contractility  of  the  muscles  is  greatly  exaggerated. 
There  may  be  slight  oedema.  Sensation  is  not  disturbed  ;  the 
mind  is  clear  ;  and  fever  is  shght  or  entirely  absent. 

Diagnosis. — Hysteria  may  be  distinguished  from  tetany  by 
the  history,  the  unHateral  character  of  the  contractions,  the 
absence  of  muscular  excitability  and  of  Trousseau's  sign. 

Tetanus. — In  this  disease  the  spasms  are  continuous  and 
early  involve  the  jaws  and  trunk. 

Prognosis. — Usually  favorable.  Attacks  following  thy- 
roidectomy and  lavage  sometimes  prove  fatal. 

Treatment. — Good  hygiene  ;  tonics  ;  electricity  ;  sedatives 
like  bromide  of  potassium,  belladonna,  and  chloral.  Warm 
or  cold  baths,  followed  by  friction. 

THOMSEN'S  DISEASE. 

(Congenital  Myotonia.) 

Definition. — A  disease  confined  to  certain  families,  and 
characterized  by  tonic  spasms  of  the  muscles,  induced  by 
voluntary  movements. 

Etiology. — The  disease  is  usually  congenital,  and  trans- 
mitted from  one  generation  to  another.  Several  members  of 
the  same  family  are  commonly  affected. 

Pathology. — Unknown. 

Symptoms. — The  disease  appears  in  early  childhood,  and  is 
manifested  by  a  tonic  spasm  of  the  muscles  every  time  they 
are  put  in  use  ;  this  is  especially  marked  after  periods  of  in- 
activity. In  a  few  moments  the  rigidity  wears  away  and  the 
moveirents   become   free.     From   repeated    contractions   the 


422  DISEASES   OF   THE   NERVOUS   SYSTEM. 

muscles  become  firm  and  extremely  well  developed.  Under 
electrical  stimulation  the  muscles  contract  and  relax  slowly. 

Peognosis. — Incurable. 

Treatment.  —  The  condition  improves  under  physical 
exercise. 

RAYNAUD'S  DISEASE. 

(Symmetrical  Gangrene.) 

Definition. — A  vaso-motor  neurosis,  characterized  by  local 
anaemia,  congestion,  or  gangrene. 

Etiology. — The  cause  is  unknown.  The  disease  probably 
consists  in  a  local  spasm  or  paresis  of  the  vessels. 

Symptoms. — In  one  form  the  part,  usually  the  finger,  be- 
comes extremely  pale,  cold,  and  angesthetic  (local  syncope). 
After  a  variable  time  these  phenomena  disappear  and  are  fol- 
lowed by  redness,  heat,  and  tingling ;  such  attacks  may  be 
excited  by  cold,  and  come  and  go  without  damaging  the  part. 

In  another  form  the  affected  part  becomes  swollen,  dark  red, 
and  painful  {local  asphyxia),  and  if  the  attack  persists  bullae 
may  appear  and  gangrene  develop.  The  gangrenous  areas 
are  often  symmetrical,  involving  a  finger  on  each  hand,  a  toe 
on  each  foot,  or  both  ears.  Hsemoglobinuria  may  occur  in,  or 
replace,  an  attack. 

Prognosis. — The  attacks  persist,  but  life  is  not  endangered. 
In  rare  instances  extensive  gangrene  develops  and  is  followed 
by  death. 

Treatment. — Patients  liable  to  attacks  should  be  well 
protected  against  cold.  Tonics  are  often  indicated.  Frequent 
bathing  followed  by  friction  is  useful.  Raynaud  advises  the 
use  of  a  continuous  current,  one  pole  over  the  spine  and  the 
other  over  the  affected  area.    Nitro-glycerine  may  prove  useful. 

ACUTE  ANGIO-NEUROTIC  (EDEMA. 

Definition. — A  neurosis  characterized  by  transient  circum- 
scribed cedema  developing  without  obvious  cause. 

Etiology. — Beyond  a  distinct  hereditary  tendency  nothing 
is  known  of  its  cause.     According  to  Quincke,  there  is  a  tem- 


FACIAL    HEMI-ATROPHY ACROMEGALIA.  423 

porary  vaso-motor  dilatation  of  the  vessels  followed  by  the 
transudation  of  serum. 

Symptoms. — CEdematous  swelling  suddenly  appears  in  some 
part  of  the  body,  particularly  in  the  face  and  hands.  Coinci- 
dent with  the  oedema  there  may  be  marked  gastro-intestinal 
symptoms  such  as  vomiting,  gastralgia,  and  colic.  The  disease 
is  allied  to  urticaria  and  the  latter  may  precede  the  outbreak. 

The  attacks  may  occur  at  intervals  of  a  few  weeks. 

Prognosis. — The  peculiar  tendency  persists ;  unless  the 
larynx  is  involved,  it  is  unattended  with  danger. 

Treatment. — General  tonics,  like  iron,  quinine,  and  strych- 
nine are  sometimes  useful. 

FACIAL,  HEMI- ATROPHY. 

(Unilateral  Progressive  Atrophy  of  the  Face.) 

Definition. — A  rare  affection,  characterized  by  progres- 
sive wasting  of  tissues — bones  and  soft  parts — on  one  side  of 
the  face. 

Etiology. — The  disease  usually  develops  in  childhood.  It 
has  been  excited  by  injury  of  the  face. 

Pathology.  —In  the  few  cases  examined  chronic  trigeminal 
neuritis  or  lesions  of  the  Gasserian  ganglion  have  been  dis- 
covered. 

Symptoms. — The  first  phenomenon  is  often  discoloration 
of  the  skin  ;  this  is  soon  followed  by  a  slow  wasting  of  all  the 
tissues  on  the  affected  side  of  the  face.  The  hair  falls,  the 
eye  recedes,  and  the  teeth  drop  out. 

Prognosis. — The  disease  is  progressive  and  incurable. 

ACKOMT]GALlA. 

(Marie's  Disease,  Pacliyacria.) 

Definition. — A  nutritional  disease,  characterized  by  en- 
largement of  the  bones  and  overlying  tissues,  chiefly  of  the 
hands,  feet,  and  face. 

Etiology. — Unknown.  It  usually  develops  in  early  life. 
A  loss  of  pituitary  secretion  is  the  probable  cause. 

Pathology. — Examination   of  the  bones  reveals  a  true 


424  DISEASES   OF   THE   NEEVOUS   SYSTEM. 

hypertrophy,  particularly  of  the  cancellous  structures.  In 
many  cases  the  pituitary  body  has  been  found  to  be  the  seat 
of  simple  hypertroj^hy,  degeneration,  adenoma,  or  sarcoma ; 
in  a  few  the  thymus  or  thyroid  gland  has  been  diseased. 

Symptoms. — The  hands  and  feet  are  considerably  enlarged, 
especially  in  breadth  ;  the  fingers  and  toes  are  stumpy  and  the 
nails  are  flat  and  small.  Hypertrophy  of  the  inferior  maxil- 
lary bone  leads  to  elongation  of  the  face  and  protrusion  of  the 
lower  jaw.  The  lips  are  large  and  everted.  Among  occa- 
sional symptoms  may  be  mentioned  spinal  curvature,  polyuria, 
glycosuria,  persistent  headache,  deafness,  blindness  from 
atrophy  of  the  optic  nerve,  loss  of  sexual  power,  and  in  women, 
menstrual  disorders. 

Diagnosis. — Acromegalia  might  be  mistaken  for  myxoe- 
deyna,  but  in  the  latter  the  soft  parts  only  are  involved ;  the 
skin  is  firm  and  adherent,  instead  of  soft  and  mobile  as  in 
acromegalia  ;  and  the  face  is  round. 

In  Paget' s  osteitis  defo7inans  the  long  bones  are  especially 
involved,  and  are  not  only  enlarged,  but  considerably  deformed ; 
and  the  face  has  a  peculiar  triangular  shape. 

Prognosis. — The  affection  is  incurable,  but  the  duration 
may  be  indefinite.  Acute  cases  lasting  two  or  three  years 
are  usually  associated  with  sarcoma  of  the  pituitary  body. 

Treatment. — So  far,  remedies  have  been  futile. 

SUNSTROKE. 

(Heat-stroke,  Thermic  Fever,  Coup  de  Soleil,  Insolation,  Heat- 
exhaustion.) 

Definition. — An  affection  resulting  from  exposure  to  ex- 
cessive heat. 

Varieties. — Two  varieties  are  observed :  Thermic  fever 
and  heat-exhaustion. 

Thermic  Fever. 

Pathology. — After  death  from  thermic  fever  rigor  mortis 
develops  early  and  is  marked.  The  various  organs,  especially 
the  brain,  are  deeply  congested.     The  left  ventricle  is  firmly 


SUXSTEOKE.  425 

contracted,  and  the  right  is  dilated  and  filled  with  blood.  The 
blood  is  dark  and  uncoagnlated.  Microscopic  examination 
of  the  tissues  reveals  parenchymatous  degeneration,  or  cloudy 
swelling. 

Symptoms. — Prodromes  are  frequently  present  and  consist 
of  exhaustion,  vertigo,  nausea,  and  headache.  These  symp- 
toms are  followed  by  coma,  and  in  this  state  the  face  is  flushed  ; 
the  eyes  are  injected  ;  the  skin  is  dry  and  burning  ;  the  tem- 
perature ranges  from  106°  to  112°  ;  the  pupils  are  contracted; 
the  respirations  are  rapid  and  noisy ;  and  the  pulse  is  full  and 
rapid.  Unless  the  temperature  soon  falls  the  respirations 
become  shallow,  the  pulse  weakens,  and  death  results  in  a 
few  hours.  There  is  a  very  malignant  form  in  which  the 
patient  is  suddenly  stricken  comatose  and  dies  in  a  few  hours 
from  cardiac  failure. 

Sequelae.  —  Meningitis;  epilepsy;  insanity;  failure  of 
memory  ;  and  extreme  sensitiveness  to  high  temperature. 

Diagnosis. — The  conditions  under  which  the  coma  has  de- 
veloped, together  with  the  extremely  high  temperature  of  the 
body,  will  serve  to  distinguish  sunstroke  from  apoplexy,  alco- 
holism, and  urgemia. 

Peognosis. — Very  guarded.  Probably  forty  per  cent, 
perish. 

Treatment. — The  patient  should  be  promptly  placed  in  a 
bath  of  ice  water  and  should  be  rubbed  with  ice.  Ice-water 
enemata  are  also  useful.  Antipyrin  has  been  administered 
subcutaneously  with  good  results.  When  the  pulse  is  full 
and  strong  venesection  may  be  a  valuable  adjunct  to  the  anti- 
pyretic treatment. 

Heat-exhaustion. 

Pathology. — According  to  Wood,  heat-exhaustion  depends 
on  a  vaso-motor  paresis,  as  a  result  of  which  there  is  a  deter- 
mination of  blood  from  the  brain  and  surface  of  the  body  to 
the  great  bloodvessels  of  the  abdomen. 

Symptoms. — The  mind  is  dazed,  but  consciousness  is  not 
lost ;  the  surface  is  pale  and  cold  ;  the  skin  is  moist ;  the  res- 


426  DISEASES    OP   THE    NERVOUS   SYSTEM. 

pirations  are  shallow  and  hurried ;  and  the  pulse  is  rapid  and 
feeble. 

PfioaNOSis. — Recovery  soon  follows  under  appropriate  treat- 
ment. 

Treatment. — The  patient  should  be  covered  with  hot 
blankets,  and  hot  bottles  should  be  placed  near  the  feet. 
Brandy,  ammonia,  and  strong  coffee  are  useful  stimulants. 
Strychnine  hypodermically  is  a  very  efficient  remedy. 

ALCOHOLISM. 

(Dipsomania.) 

Acute  Alcoholism. — After  excessive  indulgence  in  alcohol 
the  following  symptoms  are  observed :  Flushing  of  the  face, 
quickening  of  the  pulse,  and  mental  exhilaration,  followed  by 
incoherent  speech,  loss  of  coordination,  vomiting,  delirium, 
slow  pulse,  subnormal  temperature,  and,  finally,  stupor  and 
coma.  Occasionally  the  coma  is  replaced  or  interrupted  by 
convulsive  seizures.  In  the  majority  of  cases,  recovery  follows 
in  tlie  course  of  a  day  or  two  ;  but  sometimes  the  coma  deepens 
and  death  results. 

Chronic  Alcoholism. — This  condition  is  characterized  by  a 
fine  tremor,  mental  impairment,  disturbed  sleep,  injection  of 
the  conjunctivae,  redness  of  the  nose  (acne  rosacea),  and  the 
symptoms  of  chronic  gastro-intestinal  catarrh,  namely,  ano- 
rexia, coated  tongue,  fetid  breath,  nausea,  vomiting,  fulness 
and  distress  after  eating,  and  constipation  alternating  with 
diarrhoea.  When  the  habit  is  long  continued,  atheroma  of  the 
arteries,  cirrhosis  of  the  liver,  and  chronic  interstitial  nephritis 
are  apt  to  develop. 

A  very  common  complication  of  chronic  alcoholism  is 
delirium  tremens  (mania  a  potu).  This  condition  usually 
follows  a  protracted  debauch,  or  spree,  or  is  excited  by  an  in= 
jury  or  some  intercurrent  disease.  Its  chief  manifestations  are  : 
Mental  excitement,  insomnia,  incoherent  speech,  disordered 
intellect,  tremors,  and  hallucinations,  usually  of  sight  and  hear- 
ing. The  last  are  of  a  terrifying  character  ;  the  patient  hears 
threatening  voices,  or  sees  repulsive  creatures — snakes,  rats, 
loathsome  insects,  or   demons — peering  at  him  from  behind 


ALCOHOLISM.  427 

every  piece  of  furniture.  In  some  cases  the  terror  excited  by 
these  halhicinations  is  so  great  that,  in  a  fit  of  maniacal  ex- 
citement, the  patient  rushes  out  into  the  street  or  jumps  from 
the  window.  The  pulse  is  rapid  and  feeble  ;  the  appetite  is 
entirely  lost;  the  bowels  are  constipated;  and  the  temperature 
usually  elevated  (101° -103°). 

In  favorable .  cases,  in  the  course  of  a  few  days  or  a  week, 
the  excitement  abates,  the  appetite  returns,  sleep  is  restored, 
and  convalescence  established.  In  unfavorable  cases,  typhoid 
symptoms  are  apt  to  develop ;  these  are :  Irregular'  fever, 
weak  pulse,  dry,  brown  tongue,  stupor,  subsultus  teudinum, 
carphologia,  and  finally,  complete  coma. 

Among  other  comphcations  or  sequelae  of  dipsomania  may 
be  mentioned  :  Multiple  neuritis,  pneumonia,  epilepsy,  chronic 
meningitis,  paretic  dementia,  and  various  psychoses. 

Dl\gnosis. — The  coma  of  alcoholism  must  be  distinguished 
from  the  coma  of  other  diseases.  The  history,  the  absence  of 
paralysis,  the  subnormal  temperature,  the  fact  that  the  patient 
can  be  aroused  by  screaming  in  the  ear,  or  by  firm  pressure 
over  some  sensitive  spot  like  the  supraorbital  notch,  the  odor 
on  the  breath,  and  the  absence  of  other  cause"  will  usually 
prevent  an  error  in  diagnosis. 

Delirium  tremens  is  recognized  by  the  history,  restlessness, 
delirium,  tremors,  and  terrifying  hallucinations. 

The  tremors  of  chronic  alcoholism  may  be  recognized  by  the 
history,  the  associated  e\ndence  of  alcoholism,  and  by  the  fact 
that  they  are  worse  in  the  morning,  and  improve  after  the  use 
of  the  stimulant. 

Prognosis. — In  axiute  alcoholism  the  prognosis  should  be 
guardedly  favorable.  In  delirium  tremens  recovery  generally 
follows,  unless  there  is  great  debility.  In  alcoholic  pneumonia 
the  outlook  is  grave ;  recovery  is  exceptional.  In  alcoholic 
neuritis  the  symptoms  usually  subside  under  appropriate 
remedies  and  abstinence  from  the  stimulant. 

In  chronic  alcoholism  the  prognosis  is  generally  unfavorable. 
When  the  habit  is  fully  established,  it  is  rarely  permanently 
broken;- temporary  improvement  is  only  too  often  followed  by 
a  relapse. 

Treatment.     Acute  Alcoholism. — The  stomach  should  be 


428  DISEASES    OF    THE    NERVOUS    SYSTEM.  i 

emptied  by  the  stomacli-pump,  a  stimulating  emetic,  or  the 
hypodermic  injection  of  apomorphiue  (gr.  ^V"!)-  ^^  ^^^  ^^^^ 
persists  and  the  pulse  weakens,  cardiac  stimulants  like 
ammonia,  strychnia,  and  digitalis  should  be  administered 
hypodermically.  Douching  and  flagellation  may  also  be 
employed  to  arouse  the  patient. 

Delirium  Tremens. — Alcohol  must  be  withheld  unless  the 
pulse  is  very  weak.  It  is  essential  that  the  patient  should 
receive  sufficient  nourishment,  for  usually  little  food  has  been 
taken  during  the  debauch  which  led  to  the  delirium.  Highly- 
seasoned  beef-tea  and  milk  with  lime-water  are  the  best  foods. 
Sleep  must  be  secured  by  chloral  (gr.  xx),  bromide  of  potas- 
sium (3SS-3J),  hyosciue  (gr.  -^),  morphine  (gr.  ^  and  repeated 
once  or  twice),  or  paraldehyde  (3j).  When  the  pulse  is  weak 
strychnine  (gr.  ^,  repeated,  watching  the  effect)  is  often  of 
great  value.  In  most  cases  physical  restraint  is  essential ;  it 
is  best  secured  by  strapping  the  patient  to  the  bed  with  sheets. 

Chronic  Alcoholism. — It  is  necessary  that  alcohol  shall  be 
withdrawn  ;  the  rapidity  with  which  this  can  be  accomplished 
will  depend  on  the  circumstances.  In  most  cases  the  tempta- 
tion to  drink  is  so  strong  that>  confinement  in  an  inebriate 
asylum  is  essential  to  the  success  of  the  treatment.  Various 
substitutes  have  been  recommended  for  alcohol,  among  which 
may  be  mentioned  bromide  of  potassium,  chloral,  cocaine, 
hyosciue,  and  cannabis  indica.  As  a  rule,  they  accomplish 
little  beyond  quieting  the  patient  and  occasionally  securing 
sleep.  The  diet  should  be  nutritious,  and  carefully  adapted 
to  the  condition  of  the  stomach,  which  is  usually  the  seat  of 
chronic  catarrh.  Tonics  like  iron,  quinine,  and  strychnine  are 
often  indicated.  Graduated  physical  exercise  is  sometimes  of 
decided  value. 

OPIUM-POISONING. 

Acute  Poisoning,  Symptoms.  —  A  stage  of  excitement  isi 
followed  by  stupor,  coma,  contracted  pupils,  slow  respirations, 
muscular  relaxation,  and  a  slow  pulse.  In  the  final  stage  the 
respirations  become  shallow  and  irregular,  the  pulse  rapid  and 
feeble,  and  the  pupils  dilated. 


CHRONIC    LEAD-POISONING.  42;/ 

Treatment. — The  stomach  should  be  emptied  by  a  stimu- 
lating emetic  or  the  stomach-pump.  Strong  coffee  may  be 
given  by  the  mouth.  The  patient  should  be  aroused  by 
flagellation,  douching,  forced  walking,  or  the  electric  brush. 
Tiie  physiological  antidotes — atropine  and  strychnine — should 
be  given  hypodermically  in  full  doses,  their  effects  being  care- 
fully watched.  Electricity  may  be  employed  to  stimulate 
respiration. 

Morphine-habit.  {Morphinism,  Morphiomania.)  Symp- 
toms.— Ansemia,  sallow  complexion,  an  irresistible  craving 
for  the  drug,  dilated  pupils,  tremors,  loss  of  appetite,  restless- 
ness, insomnia,  mental  impairment,  and  a  complete  perversion 
of  the  moral  nature. 

Treatment. — Confinement  in  an  asylum  is  nearly  always 
necessary.  The  opium  should  be  withdrawn  gradually.  Such 
substitutes  as  cocaine,  chloral,  hyoscine,  paraldehyde,  and 
sulphonal  may  be  employed  temporarily.  Respiratory  stimu- 
lants like  strychnine,  and  cardiac  stimulants  like  digitalis,  are 
often  indicated.  In  the  vast  majority  of  cases  the  habit  is 
only  suspended,  not  broken. 

CHRONIC  LEAD-POISONING. 

(Plumbism,  Saturnism.) 

Etiology.' — Chronic  lead-poisoning  results  from  the  slow 
absorption  of  lead,  and  is  most  commonly  observed  in  work- 
men who  handle  the  metal.  Printers,  type-founders,  and 
workers  in  white-lead  are  especially  liable  to  be  affected.  Oc- 
casionally it  results  from  the  use  of  water  which  has  been 
carried  through  lead  pipes  or  which  has  been  stored  in  cisterns 
lined  with  lead. 

Pathology.  —  The  muscles  are  degenerated,  and  the  pe- 
ripheral nerves  frequently  reveal  evidences  of  chronic  neuritis. 
In  cases  associated  with  marked  muscular  atrophy,  polio- 
myelitis is  discovered. 

Symptoms. — The  following  are  the  chief  manifestations : 
Anaemia  ;  severe  colicky  pains  centering  around  the  umbilicus 
and  associated  with  retraction  and  rigidity  of  the  abdominal 
walls ;  constipation ;  a  blue  line  on  the  gums  near  the  in- 


430  DISEASES    OF    THE    NERVOUS    SYSTEM. 

sertion  of  the  teeth,  due  to  the  deposition  of  a  sulphuret  of 
lead ;  paralysis ;  tremors ;  intense  headache ;  pains  in  the 
joints  (arthralgia) ;  arterio-sclerosis ;  chronic  interstitial  ne- 
phritis ;  and  grave  cerebral  symptoms  (encephalopathies). 

The  Paralysis. — This  in  most  instances  involves  the  exten- 
sors of  both  forearms,  and  gives  rise  to  the  well-known  wrist- 
drop. In  advanced  cases  the  muscles  atrophy  and  yield  the 
reactions  of  deseneratiou.     Sensation  is  not  affected. 

Encephalopathies. — These  are  among  the  more  rare  mani- 
festations of  plumbism,  and  consist  of  convulsions,  coma, 
delirium,  intense  headache,  and  blindness  from  atrophy  of 
the  optic  nerves. 

Prognosis. — Guardedly  favorable. 

Treatment. — Prophylaxis  consists  in  absolute  cleanliness; 
the  use  of  respirators  in  lead  factories ;  the  avoidance  of 
eating  in  an  atmosphere  laden  with  the  dust  of  the  metal ; 
and  in  the  occasional  use  of  Epsom  salts. 

The  curative  treatment  consists  in  the  administration  of 
iodide  of  potassium  (gr.  v-x  thrice  daily)  and  the  use  of 
sulphur  baths.  Constipation  should  be  relieved  by  Epsom 
salts.  The  colic  may  require  the  hypodermic  injection  of 
morphine  and  atropine,  and  the  application  of  hot  fomentations 
to  the  abdomen.  The  paralysis  generally  yields  to  massage,  the 
constant  current,  and  hypodermic  injections  of  strychnine. 

CHRONIC  MERCURIAL  POISONING. 

Etiology — This  is  usually  observed  in  those  employed  in 
quicksilver  mines,  or  engaged  in  making  mirrors,  barometers, 
or  other  scientific  instruments  requiring  the  use  of  mercury. 

Symptoms. — Anaemia,  loss  of  flesh  and  strength,  gastro-in- 
testinal  disturbances,  and  marked  tremors.  The  latter  usually 
begin  in  the  extremities,  and  are  at  first  slight,  but  later  the 
whole  body  is  involved,  and  the  tremors  are  violent.  In  ad- 
vanced cases  they  may  continue  during  sleep.  Grave  cerebral 
symptoms  occasionally  develop,  such  as  vertigo,  headache,  im- 
pairment of  intellect,  convulsions,  paralysis,  and  coma. 

Diagnosis. — The  history,  the  marked  tremor  of  the  head, 


CHRONIC    ARSENICAL    POISONING.  431 

and  the  absence  of  the  peculiar  gait  (festination)  will  distin- 
guish it  from  paralysis  agitans. 

The  history,  and  the  absence  of  nystagmus  will  distinguish 
it  from  disseminated  sclerosis. 

Treatment. — Eemoval  from  the  influence  of  the  metal. 
Tonics.  Iodide  of  potassium.  Electricity.  Sedatives  for  the 
tremors. 

CHROMIC  AKSEIVICAI.  POISONING. 

Etiology. — It  is  observed  in  workmen  employed  in  arsenic 
works  and  glass  factories.  Inhaling  the  dust  of  fabrics, 
papers,  artificial  flowers  etc.,  which  have  been  colored  with 
arsenic,  may  induce  poisoning. 

Symptoms. — Anaemia,  loss  of  flesh  and  strength,  conjunc- 
tivitis, gastro-intestinal  catarrh,  loss  of  hair,  cutaneous  erup- 
tions, and  paralysis.  The  last,  unlike  that  observed  in  lead- 
poisoning,  usually  involves  the  extensors  of  the  legs,  but  later 
it  may  also  involve  the  arms. 

Treatment. — Eemoval  from  the  influence  of  arsenic. 
Tonics.     Electricity  and  massage  to  the  affected  muscles. 


DISEASES 


SKIN  AND  ITS  APPENDAGES. 


THE  COLOR  OF  THE  SKES^. 

Pallor  as  a  permanent  condition  is  generally  an  expression  of 
ansemia ;  but  it  should  be  borne  in  mind  that  in  some  cases 
the  surface  is  pale  when  the  blood  is  normally  rich  in  corpus- 
cles and  haemoglobin  ;  and  that  in  other  cases  the  surface  has 
a  natural  color  when  the  blood  is  considerably  deficient  in 
corpuscles  and  hsemoglobin.  It  follows  therefore  that  an  abso- 
lute diagnosis  of  anaemia  must  rest  on  an  analysis  of  the 
blood. 

Pallor  as  a  temporary  condition  may  result  from  emotional 
excitement,  exposure  to  extreme  cold,  shock,  syncope,  or  col- 
lapse. 

Yellowness  of  the  skin  may  result  from  jaundice,  in  which 
case  the  conjunctivse  will  also  be  yellow  and  the  urine  will 
contain  bile.  Yellowness  may  also  result  from  chlorosis  or 
pernicious  anaemia,  and  in  these  cases  the  normal  color  of  the 
conjunctivse,  the  associated  symptoms  of  the  disease,  and  the 
absence  of  bile  in  the  urine  will  indicate  the  cause. 

Whiteness  of  the  Skin A  milk-white  hue  over  extensive 

areas  may  be  observed  in  albinism,  vitiligo,  and  in  leprosy. 

Dark-brown  or  gray  discoloration  of  the  skin  is  observed  in 
the  following  conditions  : — 

Addison's  Disease. — In  this  aflFection  the  skin  has  a  bronzed 
appearance,  which  is  especially  marked  on  exposed  parts  ;  the 
(432) 


THE  COLOR  OF   THE   SKIN.  433 

buccal  mucous  membrane  may  also  reveal  discolored  plaques ; 
and  there  are  in  addition  ansemia,  prostration,  and  gastric 
irritability. 

Argyria. — This  term  is  applied  to  the  dark-gray  discolora- 
tion of  the  exposed  parts  which  follows  the  prolonged  use  of 
nitrate  of  silver.  The  discoloration  is  due  to  a  deposition 
of  the  oxide  of  silver,  and  is  more  or  less  permanent.  It  is 
said  to  be  preceded  by  a  dark  line  on  the  gums,  similar  to  the 
one  observed  in  chronic  lead-poisoning.  Formerly,  when 
nitrate  of  silver  was  used  extensively  in  the  treatment  of 
epilepsy,  it  was  not  an  uncommon  condition. 

Vagahondismus. — This  term  is  applied  to  the  dark-brown 
discoloration  of  the  skin  which  follows  prolonged  exposure  to 
the  weather,  uncleanliuess,  and  perhaps  the  irritation  of  the 
skin  resulting  from  pediculosis. 

Blueness  of  the  skin,  as  a  permanent  condition,  is  generally 
an  expression  of  cyanosis. 

Hardness,  or  Indiiratiou  of  the  Skin. 

Induration  of  the  skin  is  observed  in  scleroderma.  In  this 
affection  the  skin  is  tense,  hide-bound,  and  more  or  less  pig- 
mented. Induration  is  also  observed  in  myxcedema.  In  this 
condition  the  skin  is  swollen  as  in  oedema,  but  it  is  firm,  in- 
elastic, and  does  not  pit  on  pressure.  In  addition,  the  features 
are  peculiarly  broadened  and  the  mental  power  is  impaired. 
Circumscribed  patches  of  induration  are  observed  in  morphcea. 
The  circumscribed  patches,  with  hypersemic  or  pigmented 
borders,  and  the  smooth,  shiny,  atrophied  skin  are  the  diag- 
nostic features. 

Oedema,  or  dropsy  of  the  subcutaneous  tissues,  when  extreme, 
also  causes  induration. 

A  brawny,  indurated  condition  of  the  muscles,  especially  of 
the  legs,  is  frequently  observed  in  scurvy.     It  probably  results 
from  a  sanguineous  exudation.     The  anaemia,  purpuric  spots, 
and  spongy,  bleeding  gums  will  aid  in  the  diagnosis. 
28 


434        DISEASES   OF  THE   SKIN   AND   ITS   APPENDAGES. 

(EDEMA,  OR  DROPSY  OF  THE  SUBCU- 
TANEOUS TISSUES. 

QEdema  may  be  recognized  by  a  swelling  which  pits  on 
pressure.  It  results  from  :  (1)  Venous  stasis — from  chronic 
heart,  liver,  and  lung  disease ;  and  from  local  obstruction  to 
the  venous  circulation,  as  by  a  tumor,  pregnant  uterus,  or  a 
varicose  condition  of  the  veins.  (2)  Alterations  in  the  blood 
or  capillaries,  as  in  Bright's  disease,  anaemia,  and  inflammation. 

GLOSSY  SKIN. 

"  Glossy  Skin." — This  term  was  applied  by  Paget  to  indi- 
cate a  smooth,  atrophied,  and  shiny  appearance  of  the  skin. 
It  is  most  frequently  observed  after  inflammation  or  injury  of 
the  nerve-trunks.  It  is  sometimes  associated  with  an  intense 
burning  pain,  to  which  Mitchell  has  given  the  name  cauf^algia, 

ElSTiARGEMENT  OF  THE  SUPERFICIAL 
VEENS. 

Enlargement  of  the  superficial  veins  may  result  from 
chronic  heart,  lung,  or  liver  disease ;  from  the  pressure  of  a 
tumor  or  aneurism  on  deep-seated  veins ;  or,  as  a  general  con- 
dition, it  may  be  congenital  and  result  from  occlusion  of  deep 
veins. 

"  Caput  Medusse." — This  term  is  applied  to  a  circle  of  dilated 
veins  surrounding  the  umbilicus.  It  is  indicative  of  obstruc- 
tion to  the  portal  circulation,  and  may  result  from  atrophic 
cirrhosis  of  the  liver,  from  thrombosis  of  the  portal  vein,  or 
from  the  pressure  of  a  tumor  on  the  portal  vein. 

CUTAIVEOUS  EMPHYSEMA. 

Cutaneous  emphysema  consists  in  an  escape  of  air  into  the 
cellular  tissue.  It  is  manifested  by  a  diffuse,  pallid  swelling 
of  the  skin,  which  crackles  on  palpation  and  which  pits  on 
pressure ;  but,  unlike  oedema,  the  depression  immediately  dis- 
appears when  the  finger  is  withdrawn.     It  may  result  (1)  from 


CUTANEOUS   ERUPTIONS.  435 

traumatism  of  the  air-passages,  as  a  gunshot  wound  of  the  chest 
or  a  fracture  of  the  rib.  (2)  From  rupture  of  the  esophagus, 
stomach,  intestines,  larynx,  trachea,  or  h.mgs.  The  rupture  of 
these  organs  is  usually  due  to  ulceration,  as  in  cancer  of  the 
cesophagus,  tuberculous  cavity  of  the  lung,  or  purulent  pleurisy : 
but  occasionally  the  lung  ruptures  from  violent  strain. 

ABNORMAL  CONDITIONS  OF  THE  NAILS. 

Atrophy  of  the  Nails The  nails  may  become  dry,  brittle, 

discolored,  and  cracked  in  organic  disease  of  the  spinal  cord ; 
after  inflammation  or  injury  of  the  peripheral  nerves;  after 
prolonged  febrile  diseases,  like  typhoid  fever ;  and  in  certain 
affections  of  the  skin  which  involve  the  matrix  of  the  nail,  as 
eczema,  psoriasis,  and  ringworm. 

Curving  of  the  Nails. — Incurvation  of  the  nails  is  generally 
associated  with  clubbing  of  the  terminal  phalanges.  It  is  ob- 
served in  phthisis,  chronic  cardiac  disease,  and  in  many  wast- 
ing diseases. 

Onychia. — Inflammation  of  the  matrix  of  the  nail  may  re- 
sult from  injury  ;  from  syphilis;  from  organic  disease  of  the 
spinal  cord,  as  locomotor  ataxia ;  from  arthritis  deformans ; 
and  from  cutaneous  affections  involving  the  matrix,  as  leprosy, 
ringworm,  and  eczema. 

CUTANEOUS  ERUPTIONS. 
Macules. 

Macules  are  discolored  spots  which  are  neither  elevated  nor 
depressed. 

A  general  red  macular  ei^ujption  is  observed  in  the  following 
conditions  : — 

Syphilis. — Secondary  syphilis  may  manifest  itself  as  an 
eruption  of  small  red  macules.  They  are  usually  abundant 
and  frequently  cover  the  entire  body ;  they  lack  subjective 
symptoms ;  they  are  usually  associated  with  the  history  or 
with  the  evidences  of  syphilis,  such  as  the  scar  of  the  chancre, 
bone-pains,  alopecia,  swollen  glands,  and  sore  throat. 


436       DISEASES   OF   THE   SKIN   AND    ITS   APPENDAGES. 

Er3rtliema  Multiforme  may  manifest  itself  as  a  macular 
eruption,  but  the  macules  are  usually  associated  with  dark-red 
papules  or  tubercles.  The  multiformity  of  the  lesions ;  their 
preference  for  the  extremities  ;  their  appearance  in  successive 
crops ;  the  short  duration  of  each  lesion  ;  the  absence  of  sub- 
jective phenomena,  such  as  itching  and  burning ;  and  the 
presence  of  rheumatic  pains  are  the  diagnostic  features. 

Pityriasis  rosea. — The  eruption  is  especially  found  on  the 
trunk  ;  the  lesions  are  rose-red  in  color ;  they  are  slightly 
scaly,  the  scales  being  dry ;  subjective  phenomena  are  gener- 
ally absent ;  and  the  duration  is  a  few  weeks. 

Pediculosis  Corporis. — Lice  may  produce  a  minute  red  or 
purple  eruption.  The  small  size  of  the  lesions  ;  their  confine- 
ment to  the  covered  parts  ;  the  intense  itching  and  the  presence 
of  scratch-marks ;  and  the  discovery  of  pediculi  on  the  clothes 
are  the  diagnostic  features. 

Rbtheln. — This  affection  produces  a  macular  or  maculo- 
papular  rash  which  disappears  in  two  or  three  days  by  slight 
desquamation.  The  moderate  fever,  sore  throat,  swollen 
cervical  glands,  and  history  of  contagion  will  assist  in  the 
diagnosis. 

Accidental  Rashes. — Local  inflammation  like  tonsillitis  and 
acute  gastritis,  and  certain  drugs  and  foods  occasionally  pro- 
duce a  macular  rash. 

PurpuriG  spots,  or  hemorrhagie  macules  (petechise),  result 
from  minute  extravasation  of  blood  into  the  skin. 

A  puipuriG  eruption  is  observed  in  the  following  condi- 
tions : — 

Purpura  Hsemorrhagica  {Morbus  Ilaculosus  WerlhofH).— 
This  affection  occurs  especially  in  children  ;  it  is  associated 
with  fever  and  bleeding  from  the  mucous  membranes ;  and 
generally  runs  a  course  of  one  or  two  weeks. 

Scurvy. — This  disease  results  from  a  deprivation  of  fresh 
vegetables,  and  is  associated  with  spongy,  bleeding  gums, 
great  weakness,  and  a  brawny  induration  of  the  muscles. 

Rheumatism. — Occasionally  an  eruption  of  purpuric  spots 
appears  in  rheumatic  subjects.  It  is  usually  associated  with 
pains  in  the  limbs,  but  fever  is  generally  absent. 


CUTANEOUS   ERUPTIONS.  437 

PeliosiS  Rheumatica  {SchbnMn's  Disease). — This  is  an  acute 
affection  characterized  by  purpuric  spots,  urticaria,  sore  throat, 
moderate  fever,  and  an  inflammation  of  tlie  joints  resembling 
rheumatism.  By  some  the  disease  is  regarded  as  a  manifesta- 
tion of  rheumatism. 

Extreme  Anaemia. — A  petechial  rash  is  not  uncommon  in 
pernicious  ansemia,  leucocythsemia,  cancer,  and  advanced 
Bright's  disease.  The  history  and  the  associated  symptoms  cf 
the  original  disease  will  indicate  the  diagnosis. 

Certain  Infectious  Diseases. — In  typhus  fever  a  purpuric 
eruption  appears  on  the  fourth  or  fifth  day.  In  cerebro- 
spinal meningitis  the  eruption  is  frequently  petechial.  In 
malignant  measles  and  m  dignant  smallpox  the  rash  is  often 
hemorrhagic.  In  acute  yellow  atrophy  of  the  liver  and  in 
ulcerative  endocarditis  u  petechial  eruption  is  frequently 
observed. 

Poisoning  from  Certain  Substances. — Poisoning  from  phos- 
phorus, the  virus  of  venomous  snakes,  mercury,  and  antipyrin 
may  be  associated  with  an  eruption  of  purpura. 

Pediculosis  and  Kindred  Affections. — Body-lice,  bed-bugs, 
and  fleas  produce  petechial  lesions  which  are  surrounded  by 
slight  areolae.  The  itching,  scratch-marks,  and  discovery  of 
the  parasite  are  the  diagnostic  features. 

Brown  macules  are  observed  in  : — 

Lentigo,  or  Freckle. — The  spots  are  small,  and  are  found 
especially  on  exposed  parts — face,  neck,  shoulders,  aud  hands. 

Chloasma. — Dark  spots  may  result  from  irritation  of  the 
skin  from  the  action  of  chemicals,  heat,  scratches,  or  blisters. 
They  are  sometimes  noted  in  general  diseases  like  Addison's 
disease  and  syphilis.  They  also  occur  in  primary  affections 
of  the  skin,  as  vitiligo,  morphoea,  scleroderma,  and  leprosy. 

Moles  J  or  Wsevus  Pigmentosa. — These  consist  in  congenital 
deposits  of  pigment  on  various  parts  of  the  body. 

White  or  pale  yelloio  macules  are  observed  in  : — 

Vitiligo. — Apart  from  the  absence  of  pigment,  the  skin  is 
normal  in  appearance  and  function.  An  excess  of  pigment  is 
generally  noted  at  the  periphery  of  the  white  patches. 

Leprosy. — In  this  condition  there  are  structural  changes  in 
the  skin  and  anaesthesia  4n  addition  to  the  white  appearance. 


438       DISEASES   OF   THE  SKIN  AND   ITS   APPENDAGES. 

Morphoea. — In  the  late  stage  of  this  affection  the  circum- 
scribed patches  are  white  or  yellow.  The  structure  of  the 
skin  is  altered,  and  the  periphery  of  the  patches  is  distinctly 
hypersemic. 

Facial  Hemiatrophy. — The  onset  of  this  disease  may  be 
marked  by  the  appearance  of  a  yellow  or  white  spot  on  one 
side  of  the  face. 

Diffuse  Erythema  or  Inflainmation  of  the  Skin. 

Diff'use  erythema  or  inflammation  of  the  skin  may  result 
from  : — 

The  Action  of  Certain  Drugs  (Dermatitis  Medieamentosa). — 
Belladonna,  quinine,  chloral,  cubebs,  salicylic  acid,  and  arsenic 
may  produce  a  diff'use  red  rash. 

Scarlet  Fever.— The  history  of  contagion,  high  fever,  sore 
throat,  swollen  glands,  rapid  pulse,  and  the  punctiform  charac- 
ter of  the  rash  will  indicate  the  diagnosis. 

Rotheln. — In  some  cases  of  rotheln  the  eruption  is  red  and 
diff'use.  The  history,  slight  fever,  slight  catarrh,  and  marked 
swelling  of  the  post-cervical  glands  will  suggest  rotheln. 

Local  irritation  from  traumatism,  excessive  heat,  poisonous 
plants  or  drugs. 

Erythema  Intertrigo. — This  occurs  where  two  cutaneous 
surfaces  come  in  contact.  The  part  is  red,  moist,  and  some- 
times macerated.     The  condition  excites  a  burning  pain. 

Eczema. — The  skin  is  thickened  and  infiltrated;  there  is 
marked  itching ;  the  redness  shades  off"  gradually  ;  and  there  is 
no  fever. 

Erysipelas. — The  part  is  considerably  swollen  ;  the  redness 
and  swelling  terminate  in  an  abrupt  ridge  ;  and  the  tempera- 
ture is  high. 

Acne  Rosacea. — This  is  a  chronic  disease ;  the  redness 
appears  on  the  face,  and  is  associated  with  acne  lesions  and 
dilated  capillaries. 

Vesicles. 

A  vesicle  is  a  small  elevation  of  the  skin,  containing  serous 
fluid,  and  varying  in  size  from  a  pinhead  to  a  split-pea. 
Vesicles  are  observed  in  the  following  conditions  : — 


CUTANEOUS   ERUPTIONS.  439 

i 

Sudamen. — This  consists  of  an  eruption  of  minute  vesicles 
which  result  from  the  imprisonment  of  sweat  in  the  layers  of 
the  skin.  It  is  usually  associated  with  free  perspiration  ;  the 
vesicles  are  translucent,  lack  inflammatory  characteristics,  and 
show  no  tendency  to  rupture. 

Herpes. — The  vesicles  appear  in  groups  or  clusters  ;  they 
are  mounted  on  an  inflammatory  base  ;  they  show  no  tendency 
to  rupture ;  they  are  frequently  associated  with  burning  or 
neuralgic  pains ;  and  they  are  distributed  along  the  line  of  the 
nerve-trunks. 

Dermatitis  Venanata. —  A  vesicular  eruption  may  result 
from  contact  with  poisonous  plants,  such  as  the  poison  ivy  or 
oak.  The  eruption  generally  appears  on  the  exposed  parts — 
face  or  hands ;  the  part  is  red  and  swollen  and  there  is  intense 
itching. 

Dermatitis  Herpetiformis. — The  vesicles  are  very  irregular 
in  shape  ;  they  appear  in  clusters ;  they  are  very  tense ;  they 
show  no  tendency  to  rupture ;  they  are  frequently  associated 
with  other  lesions — papules,  pustules,  and  bullae ;  they  excite 
intense  itching ;  and  they  appear  in  crops  over  a  period  of 
weeks  or  months. 

Impetigo  Contagiosa. — The  eruption  consists  of  small  vesi- 
cles which  subsequently  enlarge  until  they  reach  the  size  of 
blebs ;  the  vesicles  appear  in  crops ;  are  commonly  discrete  ; 
are  flat  and  umbilicated  ;  are  filled  with  a  straw-colored  fluid  ; 
they  show  no  tendency  to  break,  but  dry  up  and  form  thin 
yellow  crusts,  and  they  excite  but  little  itching.  The  disease 
is  contagious  and  auto-inoculable ;  occurs  especially  in  chil- 
dren ;  and  lasts  from  one  to  two  weeks. 

Vesicular  Eczema. — The  vesicles  are  quite  small  and  are 
aggregated  in  patches ;  the  intervening  skin  is  red  and  thick- 
ened ;  the  vesicles  tend  to  break  and  pour  forth  a  serous  fluid 
which  keeps  the  part  moist;  and  the  eruption  is  associated 
with  intense  itching. 

Miliaria,  or  Heat-rash. — This  may  appear  as  an  eruption 
of  minute  vesicles ;  they  are  alway  discrete ;  they  are  sur- 
rounded by  red  areolse ;  they  usually  appear  on  the  trunk ; 
they  are   generally  associated  with   pin-head   papules ;    they 


440       DISEASES    OF   THE   SKIN   AXD    ITS   APPENDAGES. 

show  no  tendency  to  rupture  ;  and  they  excite  a  little  burning 
and  itching. 

Scabies. — In  this  affection  the  vesicles  are  small ;  they  are 
usually  associated  with  pustules  and  burroics;  they  excite  in- 
tense itching ;  and  they  are  usually  found  on  the  hands,  fore- 
arms, in  the  axillae,  under  the  mammae,  and  on  the  inner 
aspects  of  the  thighs. 

Blebs,  or  Biillse. 

A  bleb,  or  bulla,  is  a  circumscribed  eleyation  of  the  skin, 
containing  serous  fluid,  and  varying  in  size  from  a  pea  to  an 
egg.     Blebs  are  observed  in  the  following  conditions  : — 

Impetigo  Contagiosa. — The  blebs  are  flat  and  umbilicated  ; 
they  contain  a  straw-colored  fluid  ;  they  appear  in  crops  ;  they 
are  commonly  discrete ;  they  show  no  tendency  to  break,  but 
dry  up  and  form  thin  yellow  crusts ;  and  they  excite  but  little 
itching.  The  disease  is  contagious  and  auto-inoculable  ;  occurs 
especially  in  children  ;  and  lasts  from  one  to  two  weeks. 

Dermatitis  Herpetiformis. — The  bullae  are  frequently  asso- 
ciated with  papules,  vesicles,  and  pustules ;  they  are  surrounded 
by  inflamed  skin  ;  they  appear  in  clusters ;  they  show  no 
tendency  to  break,  but  dry  up  and  leave  yellowish-brown 
crusts  ;  and  they  excite  considerable  itching. 

PemphigUSi — The  bullae  appear  in  crops ;  excite  but  little 
itching  ;  they  lack  an  inflammatory  areola  ;  and  as  a  rule  they 
dry  up,  and  leave  behind  a  thin  pellicle.  The  disease  is 
generally  chronic. 

Syphilis. — The  bullous  syphilide  is  observed  in  hereditary 
syphilis,  and  very  late  in  the  acquired  disease.  The  contents 
of  the  bullae  soon  become  pustular ;  the  blebs  dry  up,  and 
form  dark -green,  cone-shaped,  stratified  crusts,  which  become 
detached  and  leave  discharging  ulcers.  The  history  and  the 
other  evidences  of  syphilis  will  aid  in  the  diagnosis. 

Pustules. 

.  A  pustule -is  a  small  circumscribed  elevation  of  the  skin 
containing  pus.  Pustules  are  observed  in  the  following  dis- 
eases:— 


CUTANEOUS   ERUPTIONS.  441 

Eczema  Pustulosum. — The  pustules  are  small ;  are  aggre- 
gated in  a  patch ;  are  generally  associated  with  minute 
vesicles ;  the  intervening  skin  is  red  and  thickened ;  and 
there  are  marked  burning  and  itching. 

Acne  Vulgaris. — The  pustules  are  usually  confined  to  the 
face,  back,  and  shoulders ;  they  have  their  origin  in  the 
sebaceous  follicles  ;  they  are  generally  associated  with  papules 
and  comedones  ;  and  they  excite  no  itching. 

Dermatitis  Herpetiformis. — The  pustules  are  frequently 
associated  with  papules  and  vesicles ;  they  are  surrounded  by 
inflamed  skin  ;  they  appear  in  clusters ;  and  they  excite  con- 
siderable itching. 

Impetigo  Simplex. — This  affection  is  usually  observed  in 
children  ;  the  pustules  are  round,  and  range  in  size  from  a 
pea  to  a  cherry  ;  there  is  only  a  slight  red  areola,  and  tin's 
finally  disappears ;  the  pustules  remain  discrete ;  they  show 
little  tendency  to  rupture,  but  dry  up  and  form  yellowish- 
brown  crusts ;  they  are  mostly  observed  on  the  extremities ; 
they  excite  no  itching.  The  disease  lasts  from  a  few  days  to 
a  week. 

Impetigo  Contagiosa. — The  eruption  is  at  first  vesicular,  but 
it  soon  becomes  pustular;  the  pustules  vary  in  size  from  a  pea 
to  a  large  marble ;  they  are  flat  and  umbilicated  ;  they  appear 
in  crops  ;  they  are  commonly  discrete  ;  they  show  no  tendency 
to  break,  but  dry  up  and  form  thin  yellow  crusts ;  and  they 
excite  but  little  itching.  The  disease  is  contagious  and  auto- 
inoculable;  occurs  especially  in  children;  and  lasts  from  one 
to  two  weeks. 

Varicella,  or  Chicken-pox. — The  pustules  result  from  vesi- 
cles ;  they  appear  especially  on  the  trunk  ;  they  are  small  and 
not  umbilicated ;  they  excite  but  little  itching.  There  is  some 
fever.     The  disease  lasts  but  three  or  four  days. 

Ecthyma. — This  disease  is  observed  especially  in  poorly- 
nourished  adults.  The  pustules  vary  in  size  from  a  pea  to  a 
cherry ;  they  are  few  in  number ;  they  are  mounted  on  an 
inflammatory  base,  and  are  surrounded  by  a  distinct  inflam- 
matory areola  ;  they  excite  but  little  itching ;  they  seldom 
break,  but  dry  up  and  form  brownish  crusts. 


442       DISEASES   OF   THE   SKIN   AND   ITS   APPENDAGES. 

Smallpox. — In  this  disease  shot-like  papules  and  umbili- 
cated  vesicles  precede  or  are  associated  with  the  pustules.  The 
latter  are  small,  surrounded  by  a  red  areola,  and  usually  excite 
some  itching.  The  high  fever  and  history  of  contagion  will 
assist  in  making  the  diagnosis. 

Syphilis. — The  pustules  are  frequently  associated  with  other 
lesions  ;  they  are  often  mounted  on  a  copper-colored  inflamma- 
tory base ;  they  excite  no  itching ;  and  they  are  usually  asso- 
ciated with  the  history  and  the  other  evidences  of  syphilis. 

Scabies. — The  pustules  are  small  and  usually  associated 
with  papules,  vesicles,  and  hurroim ;  they  are  especially  ob- 
served on  the  hands,  forearms,  in  the  axillae,  under  the  mam- 
mae, and  on  the  inner  aspects  of  the  thighs,  and  they  excite 
considerable  itching.     There  is  often  a  history  of  contagion. 

Papules. 

A  papule  is  a  circumscribed  solid  elevation  of  the  skin 
varying  in  size  from  a  pin-head  to  a  Dca.  Papules  are  ob- 
served in  the  following  conditions  : — 

Erythema  Multiforme. — The  papules  are  often  associated 
with  macules  and  tubercles  ;  they  are  flat,  and  are  of  a  bright- 
red  or  purple  color ;  they  appear  especially  on  the  extremities ; 
and  they  show  no  tendency  to  suppurate,  but  gradually  disap- 
pear in  the  course  of  two  or  three  weeks ;  they  excite  no 
itching,  but  they  are  often  associated  with  prostration  and 
rheumatic  pains. 

After  the  Use  of  Certain  Drugs. — Bromides,  iodides, 
copaiba,  cubebs,  and  tar  may  produce  a  papular  eruption. 
The  history  will  aid  in  the  diagnosis. 

Eczema  Papulosum. — The  papules  are  very  small,  closely 
aggregated,  and  often  associated  with  vesicles  and  pustules ; 
the  skin  is  thickened  ;  and  there  is  intense  itching. 

Miliaria,  or  Prickly  Heat. — The  papules  are  very  small ; 
they  are  very  often  associated  with  minute  vesicles ;  they 
always  remain  discrete  ;  they  appear  especially  on  the  trunk ; 
and  they  excite  a  little  burning  and  itching. 

Acne  Vulgaris. — The  papules  are  usually  confined  to  the 
face,  back,  and  shoulders ;  they  are  generally  associated  with 


CUTANEOUS   ERUPTIONS.  443 

pustules  and  c6medones  ;  they  involve  the  sebaceous  follicles  ; 
and  they  do  not  excite  subjective  symptoms. 

Scabies. — The  papules  are  small  and  are  usually  associated 
with  pustules,  vesicles,  and  burrows ;  they  are  especially  ob- 
served on  the  hands,  forearms,  in  the  axillae,  under  the  mam- 
mae, and  on  the  inner  aspects  of  the  thighs ;  and  they  excite 
considerable  itching.     There  is  often  a  history  of  contagion. 

Syphilis. — The  papules  are  dark  in  color ;  they  are  widely 
distributed,  being  especially  marked  on  the  trunk  and  flexor 
surfaces  of  the  extremities ;  they  are  usually  associated  with 
pustules ;  and  they  excite  no  itching.  The  history  and  the 
accompanying  evidences  of  syphilis  will  aid  materially  in 
establishing  the  diagnosis. 

Smallpox. — The  papules  are  hard  and  have  a  shot-like  feel ; 
they  soon  terminate  in  umbilicated  vesicles ;  they  excite  some 
itching,  and  they  are  associated  with  high  fever,  pain  in  the 
back,  and  often  a  history  of  contagion. 

Measles. — The  papules  are  small,  and  run  together  to  form 
crescen tic-shaped  patches  ;  and  they  are  associated  with  mod- 
erate fever,  swollen  cervical  glands,  coryza,  conjunctivitis,  and 
bronchitis.     There  is  often  a  history  of  contagion. 

Tubercles. 

Tubercles  are  large,  circumscribed,  solid  elevations  of  the 
skin  varying  in  size  from  a  large  pea  to  a  walnut.  They  are 
observed  in  the  following  conditions : — 

Erythema  Nodosum. — The  tubercles  are  large ;  they  usually 
appear  on  the  extremities ;  they  are  reddish-purple  in  color ; 
they  never  suppurate ;  and  they  are  associated  with  malaise, 
fever,  and  rheumatic  pains. 

Erythema  Multiforme. — The  tubercles  are  generally  asso- 
ciated with  macules  and  papules ;  they  are  flat,  and  are  of  a 
bright-red  or  purple  color;  they  appear  especially  on  the  ex- 
tremities, and  they  show  no  tendency  to  suppurate,  but  gradu- 
ally disappear  in  the  course  of  two  or  three  weeks.  They 
excite  no  itching,  but  are  often  associated  with  prostration  and 
rheumatic  pains.  The  disease  is  probably  allied  to  erythema 
nodosum- 


444       DISEASES   OF   THE   SKIN   AND   ITS   APPENDAGES. 

Lupus  Vulgaris. — This  may  begin  as  a  papule  or  tubercle. 
It  is  especially  observed  on  the  face.  The  tubercles  are  of  a 
pale-red  color  and  are  quite  soft  to  the  touch.  As  a  rule, 
they  slowly  brealv  down  and  form  shallow  ulcers  with  soft  red 
margins.  The  ulcers  are  painless  and  secrete  but  little  ma- 
terial. They  may  invade  all  of  the  soft  structures^  but  the 
bones  escape. 

Syphilis. — The  tubercular  syphilide  manifests  itself  as  dark- 
red  tubercles.  There  are  seldom  more  than  three  or  four,  and 
they  generally  appear  on  the  face  and  extremities.  They  are 
very  firm,  and  often  break  down,  forming  deep,  punched-out 
ulcers  which  secrete  an  abundant  purulent  material. 

Tinea  Sycosis,  or  Barber's  Itch. — The  tubercles  appear  on 
the  hairy  parts  of  the  face  and  involve  the  hair-follicles.  Sup- 
puration soon  begins  in  the  centre  of  the  tubercles,  and  the 
hairs  become  dry,  brittle,  and  loose.  The  microscope  will  re- 
veal the  tricophyton. 

Leprosy. — One  form  of  leprosy  manifests  itself  as  tubercles. 
The  latter  are  of  a  pale-red  or  yellow  color,  and  undergo  slow 
absorption  or  ulceration.  There  is  usually  more  or  less  anaes- 
thesia in  the  parts  affected. 

Wheals,  or  Pomplii. 

Wheals  are  evanescent  elevations  of  the  skin,  generally 
more  or  less  round,  and  often  white  in  the  centre  and  pale-red 
at  the  periphery.  They  excite  considerable  itching.  They 
are  observed  in  the  following  conditions  : — 

Urticaria. — The  wheals  appear  in  crops  ;  they  are  of  very 
short  duration ;  they  may  appear  on  any  part  of  the  body  ; 
and  they  excite  intense  itching. 

Erythema  multiforme,  peliosis  rheumatiea  (Schtinlein's  dis- 
ease), and  certain  insects  like  mosquitoes  also  produce  wheals. 

Crusts. 

Crusts  consist  in  dried  exudation,  and  ma}^  be  red,  yellow, 
brown,  or  green  in  color.  They  are  marked  in  the  following 
diseases : — 


CUTANEOUS   EEUPTIONS.  445 

Eczema.. — The  crusts  are  generally  associated  with  pustules 
and  vesicles;  the  surrounding  skin  is  red  and  thickened  ;  and 
there  is  considerable  itching. 

Seborrhoea. — Crusts  of  seborrhoea  are  generally  observed 
on  the  scalp.  Itching  is  absent,  and  there  are  no  evidences  of 
inflammation. 

Syphilis. — The  crusts  are  thick ;  they  are  of  a  dark-brown 
or  green  color ;  and  they  are  often  associated  with  ulcers 
which  freely  discharge.  The  history  and  other  evidences  of 
syphilis  will  aid  in  the  diagnosis. 

Impetigo. — The  crusts  are  thin  and  yellow ;  and  they  are 
associated  with  blebs  which  aj^pear  in  crops. 

Favus. — The  crusts  generally  appear  on  the  scalp  ;  they  are 
yellow,  brittle,  and  cup-shaped ;  they  are  usually  perforated 
by  a  hair,  and  have  a  peculiar  musty  odor. 

Tinea  Tonsurans,  or  Ringworm  of  the  Scalp. — In  neglected 
cases  this  affection  may  be  associated  with  crusting.  It  is 
only  observed  in  children.  The  grayish  scales,  the  dry,  brittle, 
and  broken  hairs  projecting  through  the  crusts,  the  alopecia, 
and  the  detection  of  the  tricophyton  are  the  diagnostic 
features. 

Scales. 

Scales  are  dry  exfoliations  from  the  upper  layers  of. the  skin. 
They  are  observed  in  the  following  diseases  : — 

Squamous  Eczema. — The  scales  are  usually  associated  with 
papules;  the  underlying  skin  is  red  and  thickened;  and  there 
is  often  marked  itching. 

Seborrhosa  Sicca. — The  scales  are  greasy,  and  the  under- 
lying skin  shows  no  evidence  of  inflammation.  The  sebaceous 
follicles  are  often  dilated. 

Psoriasis. — The  scales  are  dry,  and  are  of  a  pearly-white 
color  ;  they  are  associated  with  circumscribed,  sharply-defined, 
elevated  inflammatory  patches.  The  extensor  surfaces  are 
especially  involved.     There  is  little  or  no  itching. 

Ichthyosis. — This  affection  begins  in  early  life.  The  scales 
are  dry,  and  are  especially  marked  on  the  extensor  surfaces. 
Itching  is  absent,  and  there  is  no  evidence  of  inflammation. 


446       DISEASES   OF  THE  SKIN   AND   ITS   APPENDAGES. 

SypMlis. — The  scales  are  dry,  and  are  of  a  grayish  color  ; 
they  are  usually  associated  with  papules ;  and  they  are  espe- 
cially marked  on  the  palms  and  soles.  There  is  no  itching. 
The  history  and  other  evidences  of  syphilis  will  assist  in  the 
diagnosis. 

Pit3rriasis  Rosea. — The  scales  are  found  especially  on  the 
trunk,  and  are  associated  with  small,  rose-red  macules.  There 
is  no  itching.  The  disease  runs  an  acute  course  of  a  few  weeks' 
duration. 

Ringworm. — The  scales  are  dry  and  scant ;  they  are  associ- 
ated with  circumscribed  red  patches  which  tend  to  disappear 
in  the  centre.  There  is  often  marked  itching.  Microscopic 
examination  reveals  the  tricophyton. 

Ulcers. 

Ulcers  are  observed  especially  in  the  following  diseases  : — 

S3n?lulis. — The  ulcers  are  deep ;  they  have  a  punched-out 
appearance ;  they  secrete  an  abundant  oifensive  material ;  they 
often  involve  the  bone;  they  extend  rapidly;  they  are  not 
painful,  and  the  imperfect  cicatrix  which  they  produce  is  soft. 
The  history  and  other  evidences  of  syphilis  will  aid  in  the 
diagnosis. 

Epithelioma. — This  appears  in  late  life ;  there  is  usually  a 
single  centre  of  ulceration ;  the  ulcer  is  irregular  in  shape ; 
the  edges  are  thickened  and  infiltrated  ;  the  secretion  is  scanty 
and  bloody ;  the  progress  is  somewhat  slow,  and  there  is  often 
pain. 

Lupus  Vulgaris. — This  generally  appears  in  early  life ;  there 
are  often  several  centres  of  ulceration ;  the  ulcers  are  usually 
superficial ;  the  edges  are  not  thickened ;  the  progress  is  ex- 
tremely slow;  the  bones  are  never  involved;  there  is  very 
little  secretion,  and  soft  papules  often  develop  in  the  cicatrix, 
which  is  firm  and  contracted. 

Simple  Ulcers  may  result  from  traumatism,  the  application 
of  caustics,  or  the  action  of  intense  heat  or  cold.  Ulcers  are 
frequently  observed  on  the  legs  of  old  people  in  association 
with  varicose  veins.  Simple  ulcers  may  be  recognized  by  the 
history,  location,  appearance,  and  the  absence  of  other  causes. 


CUTANEOUS   ERUPTIONS.  447 

Perforating  Ulcer  of  the  Foot — This  term  is  applied  to  a 
deep-seated  ulcer  appearing  on  the  sole  of  the  foot  and  most 
frequently  observed  in  locomotor  ataxia.  It  usually  begins  as 
a  corn  in  the  neighborhood  of  the  great  toe,  and  is  generally 
associated  with  anaesthesia  of  the  sole  of  the  foot. 

Decubitus. — This  term  is  applied  to  the  bedsores  which 
form  after  the  occurrence  of  grave  cerebral  or  spinal  lesions. 
They  are  generally  observed  on  parts  which  are  subjected  to 
pressure,  as  the  sacrum,  buttocks,  calves,  and  heels,  and  are 
preceded  by  erythema  and  vesication. 


448       DISEASES   OF   THE  SKIN   AND   ITS   APPENDAGES. 

DISEASES  OF  THE  SWEAT- GLAIO)S. 

Anicli'osis. 

Definition. — A  deficiency  of  sweat. 

Etiology. — It  may  be  a  symptom  of  some  general  disease, 
like  diabetes  or  Brigh't's  disease  ;  it  may  be  an  associated  con- 
dition in  certain  cutaneous  diseases,  such  as  ichthyosis  or  psori- 
asis ;  and  it  may  develop  without  obvious  exciting  cause  as  a 
result  of  disturbed  innervation. 

Treatment. — Remedies  should  be  directed  to  the  primary 
disease. 

Hyperidi'osis. 

Definition. — Excessive  sweating. 

Etiology. — As  a  general  condition  it  is  often  observed  in 
phthisis  and  in  other  diseases  characterized  by  marked  de- 
bility. Local  hyperidrosis  is  most  frequently  observed  in  the 
hands,  feet,  and  axillee,  and  probably  results  from  some  de- 
rangement of  the  sympathetic  nervous  system.  Unilateral 
sweating  of  the  face  may  indicate  an  aneurism  or  tumor 
pressing  on  the  cervical  sympathetic. 

Symptoms. — The  primary  symptom  is  excessive  sweating, 
and  this  often  leads  to  intertrigo  or  eczema.  Bromidrosis  is 
often  associated  with  the  hyperidrosis. 

Prognosis. — Guarded.  In  many  cases  the  condition  is 
very  obstinate. 

Treatment. — Frequently  there  is  an  evident  impairment 
of  the  general .  health  which  will  require  appropriate  treat- 
ment. Internally,  one  of  the  following  remedies  may  be  em- 
ployed to  diminish  the  amount  of  sweat :  Belladonna,  picro- 
toxin,  agariciu,  or  ergot. 

Local  Treatment. — Dusting-powders  of  starch,  talc,  or  lyco- 
podium  with  boric  or  salicylic  acid ;  or  lotions  containing 
sulphate  of  zinc,  tannic  acid,  or  alum,  are  often  very  useful. 

^  Pulv.  acid,  salicylic, 
Pulv.  zinci  carb.  prsecip,, 
Pulv.  magnesii  ustte,  aa  ^iv  ; 
Pulv.  amyli,  ^xv  ; 

Pulv.  talci,  3xx.— M.     (Haedaway.) 
Sig. — Dusting-powder. 


DISEASES   OF  THE   SWEAT-GLANDS.  449 

In  hyperidrosis  of  the  feet  the  method  suggested  by  Hebra 
is  often  very  efficient.  The  feet  should  be  washed,  thoroughly 
dried,  and  then  carefully  enveloped  in  strips  of  muslin  which 
have  been  spread  with  diachylon  ointment.  The  application 
should  be  made  twice  daily.  In  the  dressing  no  water  should 
be  employed,  but  the  feet  must  be  carefully  wiped  and  then 
dusted  with  starch  or  lycopodium  before  the  ointment  is  re- 
applied. The  treatment  should  be  continued  for  from  one  to 
two  weeks,  after  which  the  feet  may  be  washed  and  the  dust- 
ing-powder alone  used 

Bromidrosis. 

(Osmidrosis.) 

Definition. — A  functional  affection  characterized  by  the 
excretion  of  sweat  which  has  a  fetid  odor. 

Symptoms. — It  is  generally  local  and  often  confined  to  the 
feet ;  it  is  frequently  associated  with  hyperidrosis. 

Tkeatment. — Same  as  hyperidrosis. 

Chromidrosis. 

Definition. — A  functional  affection  characterized  by  the 
secretion  of  colored  sweat. 

Symptoms. — The  parts  most  frequently  affected  are  the  face 
and  trunk ;  the  most  common  colors  are  red  and  yellow.  It 
is  often  associated  with  hyperidrosis. 

Suclamen. 

Definition. — A  cutaneous  aff*ection  characterized  by  the 
eruption  of  minute  vesicles  resulting  from  the  retention  of 
sweat  in  the  layers  of  the  skin. 

Etiology. — It  is  often  observed  in  health  in  persons  who 
perspire  freely.  It  is  frequently  noted  in  febrile  diseases 
which  are  associated  with  sweating,  like  pneumonia  and 
typhoid  fever. 

Symptoms. — Minute,  irregular,  translucent  vesicles  appear 
on  the  surface.  They  are  not  surrounded  by  an  inflammatory 
29 


450       DISEASES   OP  THE  SKIN   AND   ITS   APPENDAGES. 

areola.     They  do  not  rupture,  but  dry  up  and  are  followed  by 
slight  desquamation. 

Teeatment. — The  aflfection  has  little  significance  and  treat- 
ment is  rarely  required. 

nmCTIONAIi  DISEASES  OF  THE  SEBACEOUS 
GLANDS. 

Seborrhoea. 

(Steorrhcea.) 

Definition. — A  functional  afi^ection  characterized  by  ex- 
cessive secretion  of  sebaceous  material  which  may  be  normal 
or  perverted. 

Etiology. — In  many  cases  the  cause  is  not  apparent. 
Often  the  disease  is  associated  with  impairment  of  the  general 
health.     By  some  it  is  regarded  as  of  parasitic  origin. 

Varieties. — Seborrhoea  sicca  and  seborrhoea  oleosa. 

Seborrhoea  Sicca. — This  form  is  most  frequently  observed 
on  the  scalp  and  constitutes  what  is  popularly  termed  dan- 
druff. Examination  reveals  an  incrustation  composed  of  thin, 
yellowish-gray,  greasy  scales.  In  uncomplicated  cases  the 
skin  is  pale,  but  from  irritation  it  may  subsequently  become 
hyper^emic  or  inflamed.  When  allowed  to  continue,  the 
nutrition  of  the  hair  is  interfered  with  and  baldness  results. 

On  the  body  seborrhoea  sicca  appears  as  yellowish-gray 
slightly  elevated  patches  covered  with  greasy  scales.  The  out- 
lets of  the  follicles  are  often  dilated.  There  is  generally  more 
or  less  redness  of  the  skin  from  hypersemia  (seborrhceal  eczemo.) 

Seborrhoea  Oleosa. — This  form  is  most  commonly  observed 
on  the  face,  particularly  about  the  nose,  which  is  habitually 
bathed  in  an  oleaginous  material  which  has  exuded  from  the 
sebaceous  follicles.  From  irritation  the  parts  are  often  red. 
The  condition  is  frequently  associated  with  seborrhoea  sicca, 
comedo,  and  acne. 

Diagnosis.  Eczema. — In  this  disease  the  skin  is  red  and 
thickened;  there  is  marked  itching;  and  the  scales  are  not 
greasy. 


COMEDO.  .    451 

Psoriasis. — In  this  disease  the  scales  are  diy  and  pearly  and 
there  are  evidences  of  inflammation. 

Prognosis. — Favorable  under  prolonged  and  judicious 
treatment. 

Treatment — The  general  health  may  be  impaired  ;  hence 
tonics  like  iron,  strychnine,  and  cod-liver  oil  are  often  indi- 
cated. The  gastro-intestinal  tract  will  often  require  especial 
attention.  Constipation  should  be  relieved  by  diet,  enemata, 
or  mild  laxatives. 

Local  Treatment. — Crusts  should  be  removed  by  applications 
of  oil,  followed  by  shampooing  with  alcohol  and  green  soap. 
When  the  scalp  is  thoroughly  clean,  one  of  the  following 
remedies  may  be  applied  :  Sulphur,  mercury,  salicylic  acid, 
carbolic  acid,  or  resorcin. 

B     Cerse  alb.,  5ij ; 

Petrol  at.  liquid.,  f^ij  ; 

Aquse  rosse,  f3vij ; 

Sodii  borat.,  gr.  x; 

Sulphur.,  3ij.— M. 
Fiat  unguentum. 
Sig. — Apply  at  bedtime  for  several  nights,  then  shampoo. 

Or— 

^  Acid,  carbolic,  TTLxxx  ; 
Olei  rieini,  f  ^ij  ; 
Alcoholis,  fij-jvj.— M. 

(DuHEiNG  and  Stel wagon.) 
Sig. — Fill  an  eye-dropper,  introduce  between  the  hairs,  and  sub- 
sequently rub  in  by  means  of  a  flannel  rag. 

Mild  cases  of  facial  seborrhoea  often  yield  to  the  following, 
ointment : — 

1^:.  Hydrarg.  chlor.  mit.,  gr.  xx; 
Ung.  zinc,  oxid.,  §j. — M. 
Sig. — Apply  at  bedtime. 

Comedo. 

Definition. — A  functional  disease  of  the  sebaceous  glands, 
characterized  by  the  retention  of  discolored  sebaceous  material 
in  the  distended  ducts  of  the  gland. 

Etiology. — It  is  most  frequently  observed  in  young  adults. 
Debility,  gastro-intestinal  disorders,  anaemia,  and  lack  of 
cleanliness  are  predisposing  factors. 


452       DISEASES   OF  THE  SKIN   AND   ITS  APPENDAGES. 

Pathology. — The  material  in  the  ducts  is  composed  of 
sebum,  altered  epithelium,  and  pigment  matter  which  is  prob- 
ably derived  from  without.  Microscopic  examination  of  the 
material  often  reveals  a  mite — the  demodex  follicidoriim — but 
its  presence  is  accidental  and  of  no  etiological  significance. 
Comedo  is  generally  associated  with  seborrhoea. 

Syiviptoms. — The  disease  is  characterized  by  an  aggregation 
of  minute  black  or  yellowish  spots  which  correspond  to  the 
outlets  of  the  sebaceous  glands.  The  lesion  is  often  slightly 
elevated,  and  when  the  skin  is  squeezed  a  white  filiform  mass 
exudes,  to  which  the  term  "  flesh-worm"  has  been  popularly 
applied.  The  parts  most  commonly  affected  are  the  face,  back, 
and  ears.  The  condition  frequently  excites  an  inflammation 
of  the  follicles,  hence  it  is  often  associated  with  acne. 

Prognosis.  —  Favorable  under  persistent  and  judicious 
treatment. 

Treatment. — Anaemia,  dyspepsia,  and  constipation  must 
be  treated  by  a  careful  regulation  of  the  personal  hygiene,  and 
by  the  use  of  appropriate  remedies.  Tonics  like  iron,  quinine, 
cod-liver  oil,  and  strychnine  are  often  indicated. 

Local  Treatment.  —  Large  plugs  may  be  pressed  out  by 
means  of  a  watch-key  or  a  special  instrument  for  the  purpose. 
Softening  and  removal  of  smaller  plugs  may  be  hastened  by 
the  application  of  cloths  wrung  out  in  very  hot  water.  Kneed- 
ing  and  the  application  of  alcohol  and  green  soap  will  also 
assist  in  their  expulsion.  Mercury  and  sulphur  are  useful 
remedies. 

^  Hydrarg.  chlor.  corros.,  gr.  iv ; 
Alcohoiis,  f^j  ; 

Aquse  rosse,  q.  s.  ad  f^iv. — M. 
Sig.— Dab  on  twice  daily. 

Milium. 

(Grutum.) 

Definition. — An  affection  characterized  by  the  appearance 
of  small,  pearly,  non-inflammatory  elevations,  which  result 
from  the  accumulation  of  inspissated  sebum  in  ducts,  the  out- 
lets of  which  have  been  occluded. 


STEATOMA ERYTHEMA    SIMPLEX.  453 

Symptoms. — It  is  generally  observed  about  the  face,  and 
consists  of  a  collection  of  small,  round,  pearly  elevations, 
which  vary  in  size  from  a  pin-head  to  a  millet-seed.  The 
contents  of  the  distended  duct  cannot  be  squeezed  out  until 
an  opening  is  made,  and  thus  it  differs  from  comedo.  It  is 
frequently  associated  with  comedo  and  acne. 

Treatment. — Incise  the  lesion,  express  the  contents,  and 
touch  with  tincture  of  iodine. 

Steatoma. 

(Wen.) 

Definition. — A  steatoma,  or  wen,  is  a  cyst  resulting  from 
the  retention  of  secretion  in  a  sebaceous  gland. 

Symptoms. — One  or  more  rounded  or  oval  elevations,  vary- 
ing in  size  from  a  pea  to  a  large  walnut,  slowly  appear  on  the 
scalp,  face,  or  back.  They  are  painless,  rather  soft,  and  when 
opened  are  found  to  contain  a  yellowish-white  caseous  mass. 

Diagnosis.  Fatty  Tumors. — Fatty  tumors  are  rare  on  the 
scalp ;  they  are  frequently  lobulated  ;  they  have  a  doughy 
feel ;  and  are  not  so  movable  as  wens. 

Treatment. — The  sack  and  its  contents  should  be  carefully 
dissected  out.  Simple  excision  and  evacuation  are  always  fol- 
lowed by  a  return  of  the  cyst. 

ERYTHEMA  SIMPLEX. 

Definition. — Active  hypersemia  of  the  skin. 

Etiology. — It  may  result  from  exposure  to  heat  or  cold ; 
from  traumatism ;  or  from  the  application  of  some  irritating 
substance.  A  symptomatic  variety  is  frequently  observed  in 
gastric  irritation  and  systemic  diseases. 

Symptoms. — Diffuse  uniform  redness,  disappearing  on  pres- 
sure, and  without  thickening  or  elevation  of  the  skin.  When 
it  is  marked,  there  may  be  slight  burning. 

Treatment. — Sedative  lotions  or  dusting-powders. 


454       DISEASES   OF   THE  SKIN   AND   ITS  APPENDAGES. 

ERYTHEMA  EVTERTRIGO. 

(Chafing.) 

Definition. — Hypersemia  induced  by  the  attrition  of  op- 
posing surfaces  of  the  skin. 

Etiology. — It  is  common  in  children  and  in  fat  subjects. 
It  is  especially  noted  where  there  are  friction  and  perspiration, 
as  under  pendulous  mammse,  between  the  upper  parts  of  the 
thighs,  and  around  the  genitalia. 

Symptoms. — It  is  characterized  by  diffuse  redness,  and 
often  by  heat  and  moisture.  It  excites  a  burning  sensation. 
When  the  cause  is  continued  it  may  result  in  dermatitis. 

Treatment. — Apply  a  lotion  of  boric  acid  and- follow  with 
a  dusting-powder. 

ERYTHEMA  NODOSUM. 

(Dermatitis  Contusiformis.) 

Definition. — An  acute  inflammatory  disease,  characterized 
by  crops  of  large  bright-red  nodes  which  in  the  process  of  evo- 
lution assume  different  colors  as  in  the  fading  of  a  bruise. 

Etiology. — It  is  usually  seen  in  children.  It  is  frequently 
associated  with  rheumatic  and  digestive  disturbances. 

Symptoms. — There  is  a  sudden  eruption  of  bright-red 
nodes  varying  in  size  from  a  pea  to  an  egg.  The  extremities 
are  most  commonly  affected.  The  advent  is  marked  by 
malaise,  headache,  slight  fever,  and  rheumatoid  pains.  At 
first  the  lesions  resemble  boils,  but  unlike  the  latter,  they  do 
not  suppurate,  but  gradually  turn  yellow,  blue,  and  green  as  a 
bruise. 

Prognosis. — Favorable.     Duration  a  few  weeks. 

Treatment. — Saline  laxatives  and  sodium  salicylate  are 
recommended.  Locally,  lead- water  and  laudanum  make  a 
soothing  application. 

ERYTHEMA  MULTIFORME. 

Definition. — An  inflammatory  disease  characterized  by 
erythematous,  papular,  vesicular,  or  bullous  lesions. 


TJETICA.EIA.  455 

Etiology. — It  is  more  common  in  women  than  in  men. 
It  is  apt  to  develop  in  the  spring  or  fall.  Rheumatism  and 
gastro-intestinal  disturbances  seem  to  predispose. 

Symptoms. — It  is  marked  by  an  eruption,  usually  on  the 
extremities,  of  the  following  lesions  :  macules,  papules,  vesicles, 
or  bullae.  The  lesions  may  aggregate  or  remain  discrete;  they 
last  one  or  two  weeks  and  gradually  fade.  There  is  little  or 
no  itching.  In  some  cases  there  is  decided  constitutional  dis- 
turbance, manifested  by  malaise,  headache,  slight  fever,  and 
rheumatic  pains. 

Diagnosis.  Dermatitis  Hevpetiformis.  —  The  marked 
itching,  the  greater  tendency  for  the  lesions  to  cluster,  and  the 
chronic  character  of  dermatitis  herpetiformis  will  usually  pre- 
vent an  error  in  diagnosis. 

Urticaria. — In  this  disease  the  individual  lesions  last  a  very 
short  time  and  are  associated  with  marked  itching. 

Peogxosis. — Favorable.     Duration  a  few  weeks. 

Treatment. — In  tlie  debilitated  iron  and  Cjulnine  are  useful. 
In  the  rheumatic,  the  salts  of  lithium  and  of  potassium  may 
be  employed.  Constipation  should  be  relieved  by  saline  laxa- 
tives. Locally,  lotions  of  boric  or  carbolic  acid  followed  by 
dusting-powders  exert  a  beneficial  effect. 

URTICARIA. 

(Hives,  Nettle  Rash.) 

Definition. — An  inflammatory  affection  characterized  by 
the  eruption  of  pale-red,  evanescent  wheals  which  are  asso- 
ciated with  severe  itching. 

Etiology. —  Gmstro-intestinal  disturbances,  emotional  ex- 
citement, and  chronic  visceral  diseases  predispose.  In  some 
it  may  be  excited  by  certain  articles  of  food  such  as  shell- 
fish, strawberries,  etc.  The  bites  of  certain  insects  produce  the 
disease,  such  as  mosquitoes,  bed-bugs,  and  caterpillars.  Some 
drugs  induce  urticaria  in  susceptible  people. 

Pathology. — The  disease  consists  in  a  vaso-motor  spasm, 
followed  by  paresis  of  the  vessels  and  an  outpouring  of  serum. 

Symptoms. — There  is  a  sudden  general  eruption  of  papules 
or   wheals  w^hich   is  associated   with  intense  itching.     Each 


456        DISEASES   OF  THE  SKIN   AND   ITS   APPENDAGES. 

lesion  lasts  a  few  hours  and  is  succeeded  by  new  ones  in  other 
places. 

Varieties.  Urticaria  Papulosa. — In  this  form  the  wheal 
is  followed  by  a  lingering  papule  which  is  attended  by  consid- 
erable itching.     It  is  most  commonly  observed  in  children. 

Urticaria  Hemorrhagica.—  The  lesions  are  infiltrated  with 
blood. 

Urticaria  Tuberosa  (Giant  Urticaria). — In  this  form  the 
wheals  may  reach  the  size  of  an  egg. 

Diagnosis.  Erythema  Multiforme  and  Erythema  Nodo- 
sum.— In  both  of  these  affections  the  lesions  last  much 
longer,  and  are  free  from  itching. 

Prognosis. — Favorable.  In  some  cases  it  tends  to  become 
chronic. 

Treatment. — The  cause  should  be  removed  when  possible. 
In  gastric  irritation  bismuth,  or  calomel  and  soda  are  useful. 

When  there  is  constipation  a  saline  laxative  may  prove  very 
efficient.  The  special  remedies  usually  recommended  are  alka- 
lies, salicylate  of  sodium,  quinine,  iodide  of  potassium,  and 
atropine. 

Locally,  lotions  of  water  and  alcohol,  carbolic  acid,  boric 
acid,  or  hydrocyanic  acid  are  very  useful : 

^  Acid,  carbolic,  Sj-gij  ; 
Glycerini,    f^ss  ; 
Alcohol.,  flgvj  ; 
Aquse,  q.  s.  ad  Oj. — M. 

Urticaria  Pigmentosa. 

This  is  a  form  of  urticaria  observed  in  young  children.  It 
is  characterized  by  an  eruption  of  wheals  which  are  itchy  and 
persistent,  and  which  leave  behind  a  yellowish  or  brownish 
pigmentation.  The  disease  runs  a  chronic  course  of  months  or 
years. 

HERPES  SIMPLEX. 

(Fever  Blisters.) 

Definition. — An  acute  non-contagious  disease,  character- 
ized by  groups  of  small  vesicles  mounted  on  inflammatory 
bases. 


HERPES   ZOSTEE.  457 

Etiology. — Herpes  is  very  common  in  febrile  diseases, 
especially  pneumonia,  influenza,  malaria,  and  cerebro- spinal 
meningitis.  Local  irritation  also  predisposes  to  it.  It  is  de- 
pendent upon  a  peripheral  toxic  neuritis. 

Sy^iptoms. — One  or  more  clusters  of  small  vesicles  appear, 
usually  on  the  face  or  genitalia.  The  vesicles  are  mounted  on 
an  inflammatory  base,  contain  clear  fluid,  and  show  no  ten- 
dency to  rupture.  Soon  their  contents  become  puriform,  dry 
up,  and  form  reddish-brown  crusts  which  fall  off  in  a  few 
days.  Burning  and  tingling  precede  and  accompany  the 
eruption. 

Varieties. — When  it  appears  on  the  face^  it  is  termed 
herpes  facialis  ;  on  the  genitals,  herpes  progenitalis. 

Diagnosis. — Herpes  progenitalis  must  be  distinguished 
from  chancroid.  The  history,  the  superficial  character  of  the 
lesion,  the  burning  pain,  and  the  subsequent  course  will  indi- 
cate herpes. 

Treatment. — The  lesion  may  be  painted  with  flexible 
collodion,  or  the  following  lotion  employed  : — 

^   Zinc,  oxid.,  gr.  xv  ; 
Glycerini,    ITL  xv ; 
Liq.  plumbi  subacetat.  dil.,  V([  x  ; 
Liq.  calcis,  3vj-|j.— M.     (Tilbury  Fox.) 
Sig. — Apply  locally. 

HERPES  ZOSTER. 

(Zona,  Shingles.) 

Definition. — An  acute  inflammatory  disease  characterized 
by  groups  of  small  vesicles  mounted  on  inflammatory  bases, 
associated  with  neuralgic  pain,  and  following  the  distribution 
of  certain  nerve-trunks. 

Etiology. — The  disease  commonly  depends  upon  a  periph- 
eral neuritis.  Injury,  exposure  to  cold,  and  damp  clothes 
predispose  to  it. 

Symptoms. — Clusters  of  vesicles  mounted  on  inflammatory 
bases  may  appear  on  any  part  of  the  body  ;  but  they  are  most 
frequently  observed  along  the  course  of  the  intercostal  nerves. 
Only  one  side  is  affected.  Sharp  neuralgic  pain  precedes  and 
accompanies  the  eruption.     The  fluid  in  the  vesicles  soon  be- 


458       DISEASES  OF  THE  SKIN  AND  ITS   APPENDAGES. 

comes  turbid,  dries  up,  and  forms  jellowish-brown  crusts 
which  fall  off  in  a  few  days. 

Prognosis. — Favorable. 

Treatment. — Tonics  are  often  indicated.  Bulkley  recom- 
mends phosphide  of  zinc  in  doses  of  one-third  of  a  grain  every 
three  hours.  Morphine  is  sometimes  required  for  the  relief 
of  pain.     Phenacetine,  however,  usually  gives  relief. 

Locally. — Sedative  applications  are  required ;  the  best  are 
flexible  collodion  with  morphine,  or  a  solution  of  menthol  or 
carbolic  acid,  followed  by  a  dusting-powder  of  oxide  of  zinc 
or  starch. 

^  Morph.  sulph.,  s;r.  viij  ; 
Collodii,  f^j.— M. 
Sig. — Apply  with  a  camel's-hair  brush. 

HERPES  IRIS. 

Definition. — An  inflammatory  disease,  characterized  by 
groups  of  vesicles  arranged  in  concentric  rings  which  present 
a  somewhat  variegated  appearance. 

Etiology. — The  causes  are  unknown.   The  disease  is  rare. 

Symptoms. — One  or  more  rings  of  vesicles  successively 
appear  around  a  central  vesicle  or  papule.  The  different  ages 
of  the  rings  which  compose  the  patch  impart  to  the  latter  a 
variegated  appearance.  Burning  and  itching  are  often  atten- 
dant symptoms.  The  hands,  arms,  and  feet  are  the  parts  most 
frequently  affected.  The  lesions  appear  in  successive  crops 
over  a  period  of  several  weeks.  In  some  instances  the  vesicles 
are  quite  large  and  resemble  the  blebs  of  pemiphigus. 

Prognosis. — Favorable,  but  recurrent  attacks  are  common. 

Treatment. — The  same  as  in  herpes  zoster. 

agist:. 

(Acne  Vulgaris.) 

Definition. — An  inflammatory  disease  of  the  sebaceous 
glands,  characterized  by  papules  and  pustules  and  usually 
seated  on  the  face  or  back. 


ACNE.  459 

Ettolo(?v. — It  generally  develops  about  puberty.  Ansemia, 
menstrual  disorders,  and  gastro-intestinal  disturbances  predis- 
pose. Certain  diujis  like  iodide  and  bromide  of  potassium 
and  copaiba  may  induce  the  disease. 

Pathology. — Acne  lesions  result  from  the  irritation  ex- 
cited by  retained  sebaceous  matter,  hence  the  papules  and  pus- 
tules are  commonly  associated  with  blackheads,  or  comedones. 

Symptoms. — An  aggregation  of  small  papules,  pustules, 
and  comedones  about  the  face,  chest,  and  shoulders.  Pustules 
or  papules  predominate  according  as  the  disease  is  acute  or 
chronic.  New  lesions  develop  as  the  old  disappear,  so  that 
the  disease  usually  runs  a  protracted  course.  Subjective  phe- 
nomena are  absent. 

Vaeieties.  Acne  Papulosa. — In  this  form  the  lesion 
reaches  the  papular  stage  and  advances  no  further. 

Acne  Pustulosa. — In  this  variety  the  papules  develop  into 
pustules. 

Acne  Inclurata. — The  inflammation  is  deeply  seated,  the  base 
of  the  papule  or  pustule  is  firm,  and  the  lesion  is  sluggish. 

Acne  Atrophica. — In  this  form  the  lesions  are  followed  by 
small  scars  or  pits. 

Acne  Hypertrophica. — In  this  form  there  is  an  overgrowth 
of  connective  tissue  and  the  skin  becomes  thickened. 

Diagnosis. — The  distribution,  the  chronic  character  of  the 
affection,  the  involvement  of  the  sebaceous  glands,  and  the  as- 
sociation with  comedones  are  the  diagnostic  features  which 
separate  acne  from  all  other  affections. 

Prognosis. — Curable  under  persistent  treatment. 

Treatment. — The  general  health  must  be  improved.  The 
diet  should  be  nutritious,  but  easily  assimilable;  rich  food  must 
be  prohibited.  Constipation  should  be  relieved  by  mild  laxa- 
tives. In  the  ansemic  and  debilitated  iron,  quinine,  strychnine, 
and  cod-liver  oil  are  useful  remedies.  The  special  drugs  wdiich 
have  been  recommended  are  arsenic,  ergot,  and  calx  sulphurata. 
Arsenic  is  best  suited  to  the  sluggish  indurated  forms  ;  and 
calx  sulphurata  (gr.  yq-^  four  times  daily)  to  the  pustular 
variety. 

Local  Treatment. — In  the  acute  form  mild  applications 
should  be  employed,  like  the  following  calamine  lotion  : — 


460       DISEASES   OF   THE   SKIN  AND   ITS   APPENDAGES. 

^  Pulv.  zinc,  oxid.,  ^iij  ; 
Pulv.  calaminse,  gij  ; 
Glycerini,    fgij  ; 
AquiB  calcis,  ^vj. — M. 

In  chronic  cases  the  sebaceous  phigs  should  be  removed  by  a 
watch-key  and  the  pustules  incised.  Thorough  washing  with 
very  hot  water  and  green  soap  is  also  advisable.  The  best 
local  remedies  are  sulphur,  mercury,  and  resorcin. 

]^  Calcis,  ^ss ; 

Sulphur,  sublitnat.,  5j  ; 
Aqure,  gx.— M,     (Vlejiincks.) 
Evaporate  to  six  ounces  and  filter. 

Sig. — Apply  at  first  well  diluted  and  gradually  increase  the 
strength. 

Or— 

1^:.   Sulphur,  prpecip.,  3j  ; 
Ung.  aqupe  rosa?, 

Petrolat.  moll,  aa  giv.— M.    (Yan  Haklingen.) 
Sig. — Apply  night  and  morning. 

Or— 

^  Hydrarg.  aramoniat.,  gr.  xx-xl ; 
Ung.  aquK  rosee,  gj. — M. 
Sig. — Use  night  and  morning. 

Or— 

R     Hydrarg.  chlor.  corrosiv.,  gr.  ss-ij  ; 
Emuls.  amj^gdal.  amar.,  fgiv ; 
Tinct.  benzoin.  comp.,f3j. — M. 
Sig. — Use  locally. 


ACNE  ROSACEA. 

Definition. — A  chronic  aifection,  usually  located  on  the 
face  in  the  region  of  the  nose,  and  characterized  by  marked 
hypersemia,  dilatation  of  the  vessels,  overgrowth  of  tissue,  and 
acne  lesions. 

Etiology. — Ansemia,  menstrual  disorders,  gastric  disturb- 
ances, exposure  to  extremes  of  temperature,  and  intemperance 
are  the  usual  predisposing  causes. 

Symptoms. — The  affected  area  is  of  a  deep-red  color ;  the 
vessels  are  dilated ;  the  skin  is  thickened  and  lumpy,  and 


FDRUNCULUS.  46  J 

acne  lesions  coexist.  In  advanced  cases  the  nose  may  become 
extremely  large  and  lobulated  (Rhinophyma). 

Subjective  phenomena  are  generally  absent. 

Diagnosis.  Lupus  Vulgaris. — In  this  disease  there  are 
soft  pale-red  papules,  ulceration,  and  cicatrization,  and  no  en- 
largement of  the  bloodvessels. 

Prognosis. — Unless  the  hypertrophy  is  marked,  the  dis- 
ease is  curable  under  protracted  treatment. 

Treatment. — The  general  treatment  is  the  same  as  in  acne 
vulgaris. 

Local  Treatment. — Sulphur  and  mercury  are  the  most  reli- 
able remedies.  Vleminckx's  solution  is  very  useful.  Dilated 
vessels  should  be  destroyed  by  electrolysis.  Large  hypertro- 
phies may  be  removed  by  the  knife. 

FURUNCULUS. 

(BoU.) 

Definition. — An  acute,  circumscribed  inflammation  of  a 
sebaceous  gland  or  hair-follicle,  usually  terminating  in  sup- 
puration. 

Etiology. — Single  boils  are  usually  due  to  local  irritation. 
Their  appearance  in  crops  (Furunculosis)  is  usually  indicative 
of  impaired  health.  The  entrance  of  pus  cocci  into  the  skin 
is  always  essential  to  their  production. 

Diagnosis. — Furuncles  must  be  distinguished  from  carbun- 
cles ;  the  latter  are  single,  large,  flattened  at  their  summits,  and 
have  multiple  openings. 

Treatment. — In  furunculosis  the  cause  should  be  searched 
for  and,  if  possible,  removed.  Tonics  like  iron,  quinine,  cod- 
liver  oil,  and  hypophosphites  are  often  very  useful.  Calx 
sulphurata  (yV4"  g^-  t^^^ice  daily  after  meals)  sometimes  proves 
serviceable.  A  solution  of  boric  acid  or  of  corrosive  sublimate 
may  be  applied  locally.  The  following  paste  will  often  abort 
them  : — 

Ichthyol, 
Ung.  hydrarg., 
Ext.  belladonnse,  aa  ^j. — M. 
Sig.— Apply  locally  and  make  pressure  with  strips  of  adhesive 
plaster. 


462       DISEASES  OF   THE  SKIN   AND   ITS   APPENDAGES. 

CARBUNCULUS 

(Anthrax.) 

Definition. — A  circumscribed  inflammation  of  the  skin 
and  deeper  tissues,  characterized  by  a  dark-red,  painful  node 
which  breaks  down  and  evacuates  through  several  apertures. 

Etiology. — Lowered  vitality  from  any  cause  predisposes. 
They  are  especially  common  in  diabetes.  The  exciting  cause 
is  a  special  microbe. 

Symptoms. — A  dark-red,  painful,  flattened  node  appears 
surrounded  by  a  dusky-red  area  of  induration.  In  a  week  or 
ten  days  suppuration  begins,  and  the  contents  are  discharged 
through  several  orifices.  There  is  generally  marked  con- 
stitutional disturbance.  The  most  common  seats  are  the  nape 
of  the  neck,  back,  and  buttocks. 

Prognosis.  —  Guardedly  favorable.  Death  is  not  an  in- 
frequent termination  in  the  old  and  debilitated. 

Treatment. — Generally  tonics  like  quinine,  iron,  and 
whiskey  are  indicated.  Opium  may  be  required  to  relieve 
pain. 

Local  Treatment. — In  the  early  stage  they  may  be  aborted 
by  a  central  injection  of  ten  to  twenty  minims  of  a  5  or  10  per 
cent,  solution  of  carbolic  acid  in  glycerine.  When  not  seen 
until  abortion  is  too  late,  firm  compression  may  be  made  by 
straps  applied  concentrically,  leaving  the  central  orifice  free 
for  the  discharge  of  sloughs  ;  an  antiseptic  dressing  may  be 
applied  over  the  straps. 

PSORIASIS. 

Definition. — A  chronic  inflammatory  disease,  character- 
ized by  red,  scaly,  sharply-circumscribed,  elevated  lesions. 

Etiology. — Psoriasis  usually  develops  in  young  adults. 
Heredity,  the  gouty  diathesis,  pregnancy,  and  lactation  seem  to 
predispose.  It  is  as  common  in  the  robust  as  in  the  debilitated. 
It  is  non-contagious. 

Pathology. — A  localized  hypertrophy  of  the  rete  mucosum 
associated  with  inflammation. 


psoEiAsis.  463 

Symptoms. — Little  red  spots  appear  on  the  body,  and 
gradually  grow  until  they  reach  the  size  of  a  dollar.  The 
lesions  are  of  a  dull  pink  or  red  color,  sharply  defined,  some- 
what elevated,  surrounded  by  healthy  skin,  and  covered  with 
abundant  dry,  pearly,  overlapping  scales.  These  scales  are 
readily  detached,  leaving  behind  a  dry,  slightly  excoriated 
surface.  The  lesions  may  be  uniformly  distributed  over  the 
entire  body,  but  usually  the  extensor  surfaces  are  more  affected ; 
a  symmetrical  arrangement  is  often  observed.  Itching  is 
slightly  or  entirely  absent.  After  a  variable  time  the  centre  of 
the  patch  disappears  and  leaves  behind  a  spot  of  healthy  skin 
which  gradually  increases  until  no  trace  of  the  lesion  remains. 
The  disease  runs  a  protracted  course  of  months  or  years,  im- 
proving in  the  summer  and  growing  worse  in  the  winter. 

Diagnosis.  Eczema. — In  this  disease  the  patches  are  not 
sharply  defined,  but  shade  off  gradually  into  the  surrounding 
skin ;  there  is  marked  itching ;  there  is  usually  a  decided  dis- 
charge, and  healing  begins  at  the  periphery  instead  of  at  the 
centre  as  in  psoriasis. 

Seborrhoea. — In  this  affection  the  lesions  are  usually  confined 
to  the  scalp  and  face,  while  psoriasis  is  general ;  the  scales  are 
gray  and  greasy  ;  the  patches  are  not  circumscribed,  and  lack 
the  inflammatory  character  of  psoriasis. 

Papulosquamous  Syphiloderitn. — The  history,  the  associated 
symptoms  of  syphilis,  the  coppery  color  of  the  lesions,  the 
scant  scaling,  the  special  tendency  to  involve  the  hands  and 
soles  will  render  the  diagnosis  apparent. 

Prognosis. — The  disease  disappears  under  treatment,  but 
relapse  generally  follows  after  a  longer  or  shorter  period. 

Treatment. — The  general  health  may  require  attention. 
In  the  gouty  alkalies  are  of  value  ;  and  in  the  anaemic  iron  and 
cod-liver  oil  are  indicated.  Arsenic  is  often  of  considerable 
value ;  it  should  be  given  in  small  doses  cautiously  increased. 
Iodide  of  potassium  (gr.  x-xx  thrice  daily)  is  sometimes  rec- 
ommended. 

Local  Treatment. — The  scales  should  be  removed  by  alkaline 
baths  before  local  applications  are  made.  The  best  local 
remedies  are  tar,  chrysarobin,  salicylic  acid,  resorcin,  sulphur, 
and  ammoniated  mercury. 


464       DISEASES   OF   THE  SKIN   AND   ITS   APPENDAGES. 

^  Acid,  chrysophanic,  gr.  x; 
Adipis  benzoat.,  §j. — M. 
Sig.  — Apply  twice  daily. 

Or— 

ji^:.   Sulphur,  sublimat., 
01.  cadini,  aa  ^iv  ; 
Sapon.  virid., 
Adipis,  aa  §j  ; 
Cretse  prsep.",  sijss. — M.     (Wilkinson.) 

ECZEMA. 

(Tetter.) 

Definition. — A  non-contagious  inflammatory  disease  of 
the  skin,  characterized  by  multiform  lesions — erythema,  pap- 
ules, vesicles,  pustules,  scales,  and  crusts — and  associated  with 
infiltration,  itching,  and  more  or  less  discharge. 

Etiology. — It  is  most  common  in  the  young  and  in  the 
aged.  Digestive  disturbances,  debility,  gout,  and  rheumatism 
predispose  to  its  development.  It  may  be  due  to  external 
irritants  like  cold,  heat,  the  rhus-plant,  hard  soaps,  certain 
dyes,  etc. 

Pathology. —  Congestion  and  infiltration  of  the  various 
layers  of  the  skin. 

Varieties. — E.  erythematosum,  E.  papulosum,  E.  vesicu- 
losum,  E.  pustulosum,  E.  squamosum,  and  E.  rubrum. 

Eczema  Erythematosum. — This  form  consists  in  irregular 
patches  marked  by  swelling,  redness,  and  slight  scaling,  and 
accompanied  by  itching  and  burning.  The  most  common  seat 
is  the  face. 

Eczema  Papillosum, — In  this  form  there  is  a  close  aggrega- 
tion of  minute  acuminated  papules  accompanied  by  severe 
itching.  It  is  frequently  associated  with  the  vesicular  variety. 
The  most  common  seat  is  the  extremities. 

Eczema  Vesiculosum. — This  consists  in  an  ill-defined  red 
patch  surmounted  by  minute  vesicles,  and  accompanied  by 
intense  itching.  The  vesicles  soon  rupture  and  leave  a  raw, 
weeping  surface  which  becomes  more  or  less  covered  with 
crusts.  In  childi'en,  it  is  most  common  on  the  face  ;  in  adults, 
on  the  extremities. 


ECZEMA.  465 

Eczema  PustuloSlim  (Eczema  Impetiginosum). — This  consists 
in  an  aggregation  of  small  pustules  which  break  and  lead  to  the 
formation  of  thick  yellowish  crusts.  Itching  is  not  marked. 
It  is  frequently  associated  with  the  vesicular  variety.  It  is 
most  commonly  observed  on  the  face  and  scalp  of  poorly- 
nourished  children. 

Eczema  Squamosmnc — In  this  form  there  are  irregular  ill- 
defined  red  patches  accompanied  by  considerable  scaling.  It 
differs  from  the  erythematous  form  in  the  large  amount  of 
scaling.     Its  most  common  seat  is  the  scalp. 

When  there  is  a  marked  tendency  to  Assuring,  as  in  chap- 
ping,  this  form  is  termed  eczema  Jissum  ;  and  when  there  is  a 
tendency  to  the  formation  of  warty  excrescences,  it  is  termed 
eczema  verrucosum. 

Eczema  Rubrum  (Eczema  Madidans). — This  is  a  secondary 
variety  and  is  recognized  by  a  raw,  dark-red,  moist  surface, 
more  or  less  covered  with  thick  yellowish-red  crusts.  The 
itching  may  be  severe.  In  children  it  is  frequently  noted  on 
the  face,  and  in  old  people  on  the  extremities. 

Diagnosis,  Scabies. — The  history  of  contagion ;  the  loca- 
tion of  the  lesions — between  the  fingers,  on  the  wrists,  under 
the  mammae,  in  the  axillae ;  and  the  presence  of  burrows  will 
indicate  scabies. 

Psoriasis. — The  sharply-defined  patches,  the  dry  scaling, 
the  absence  of  marked  itching,  the  symmetrical  distribution, 
and  the  predilection  for  extensor  surfaces  will  indicate 
psoriasis. 

Acne  Rosacea. — The  presence  of  acne  pipules  and  pustules 
and  of  dilated  bloodvessels,  and  the  absence  of  itching  will 
distinguish  acne  rosacea  from  erythematous  eczema. 

Sehorrhoea. — The  greasy  scales  and  the  absence  of  itching 
and  of  all  inflammatory  symptoms  will  indicate  seborrhoea. 

Sycosis. — The  limitation  of  the  lesions  to  the  hair-follicles 
of  the  face  and  the  absence  of  itching  will  distinguish  sycosis 
from  eczema. 

Peognosis. — Generally  favorable  under  persistent  and  judi- 
cious treatment. 

Teeatment.      General  Treatment. — The   health   must   be 
improved.     Tonics  are  frequently  indicated.      In  strumous 
30 


466       DISEASES   OF   THE  SKIN   AND   ITS   APPENDAGES. 

children  cod-liver  oil  may  be  of  extreme  value.  Disturbances 
of  the  gastro-intestinal  tract  are  frequently  present,  and  will 
require  appropriate  treatment.  In  the  gouty  and  rheumatic 
the  alivaline  mineral  waters,  colchicura,  and  the  salts  of  lithium 
are  indicated.  Constipation  must  always  receive  attention. 
Of  the  special  internal  remedies,  arsenic  is  the  most  important ; 
it  is,  however,  only  indicated  in  the  chronic  cases  in  which 
bright  redness,  itching,  and  weeping  are  absent. 

External  Treatment. — In  acute  cases  with  marked  inflam- 
matory symptoms,  soothing  applications  should  be  employed. 
A  saturated  solution  of  boric  acid  may  be  dabbed  on  for  five 
or  ten  minutes,  and  may  be  followed  by  zinc  ointment  spread 
on  lint ;  when  there  is  much  itching  carbolic  acid  is  very 
useful : — 

j^:    A.cid.  carbolic,  3j; 
Glyceriui,    ^ij  ; 
Aquse,  q.  s.  ad  f^viij. — M. 

Sig. — Apply  locally. 

The  following  is  also  frequently  used : — 
1^  Zinc,  oxid.,  ^ss; 

Pulv.  calaminse  prsep.,  9iv  ; 

Glycerini,    fjj  ; 

Liq.  calcis,  f^vij. — M. 
Sig. — Shake  and  apply  locally. 

In  chronic  cases  crusts  and  scales  should  be  removed  by 
soap  and  water  or  by  : — 

^   Saponis  virid.,  |ij  ; 
Alcoholis,  5j.— M, 
Sig. — Apply  thoroughly  and  remove  with  warm  water. 

The  best  external  applications  are  salicylic  acid,  tar,  mer- 
cury, and  resorcin : — 

^   Acid,  salicylic,  gr.  v-x; 
Petrolat.  moll.,  3iv ; 
Amyli, 
Zinci  oxid.,  aa  3ij.— M. 

(Stelwagon  and  Duhklng.) 
Sig. — Apply  twice  daily. 

Or— 

]^  Hydrarg.  ammoniati,  ^ss  ; 
Liq.  picis  alkaliu.,  gj  ; 
Ung.  aquse  rosse,  §j.— M. 


LICHEN    RUBER   AND    LICHEN   PLANUS.  467 

Or— 

^  01.  cadini,  f^ss ; 
Glycerini,    fgj  ; 

Ung.  diachyli,  f^iiss,— M.      (TiLBURY  Fox.) 
Sig. — Apply  locally. 

LICHEN  RUBER  AND  MCHEN  PLANUS. 

Lichen  Ruber. — This  is  an  extremely  rare  disease,  charac- 
terized by  the  eruption  of  small,  red,  glazed,  acuminated  papules 
which  show  no  tendency  to  coalesce,  and  which  are  associated 
with  itching  and  failure  of  general  health.  The  disease  runs 
a  chronic  course,  and  may  prove  fatal  through  exhaustion. 

Lichen  Planus. — This  form  is  characterized  by  an  eruption 
on  the  extremities  of  small,  red,  flat  papules  which  tend  to 
spread,  and  by  coalescing  form  dull-red,  irregular  patches. 
The  lesions  have  an  angular  outline,  are  slightly  umbilicated, 
and  at  first  have  a  smooth  and  shiny  appearance,  but  later 
are  slightly  scaly.  There  is  more  or  less  itching,  but  no 
impairment  of  the  general  health.  As  the  old  lesions  disap- 
pear new  ones  take  their  place. 

Etiology. — These  affections  are  most  frequently  observed 
in  poorly-nourished,  middle-aged  males. 

Treatment. — The  general  health  must  be  improved  by 
good  food  and  such  tonics  as  iron,  strychnine,  and  cod-liver 
oil.  Arsenic  is  of  considerable  value.  Locally,  ointments  of 
tar  or  mercury  are  useful. 

Lichen  Scrofulosis. 

This  is  a  chronic  affection  occurring  chiefly  in  children  of  a 
strumous  diathesis,  and  characterized  by  small,  pale-red,  or 
salmon-colored  scaly  papules.  They  tend  to  form  in  groups, 
and  are  most  frequently  observed  on  the  trunk.  Itching  is 
absent.     The  disease  runs  a  chronic  course. 

Treatment. — Remedies  like  iron,  quinine,  and  cod-iiver 
oil  are  indicated.  Hebra  recommends  the  last  remedy  as  a 
local  application. 


468        DISEASES   OF   THE  SKIN   AND   ITS   APPENDAGES. 

PRURIGO. 

Definition. — A  chronic  inflammatoiy  disease,  characterized 
by  a  general  eruption  of  minute,  discrete  papules,  accompanied 
by  marked  itching. 

Etiology. — It  is  most  commonly  observed  in  the  poor  and 
ill-fed  of  Europe.  It  develops  in  early  childhood  and  persists 
through  life. 

Symptoms. — An  eruption  of  small,  discrete,  deeply-situated, 
pale-red  papules  appears  on  the  body,  especially  on  the  back 
and  extensor  surfaces  of  the  extremities.  The  skin  is  harsh, 
dry,  and  thickened,  and  covered  with  numerous  scratch-marks 
induced  by  the  intense  itching. 

Prognosis. — Unfavorable ;  it  usually  persists  through  life. 

Treatment. — The  general  health  must  be  improved  by 
good  food  and  the  use  of  nutrient  tonics  like  iron  and  cod- 
liver  oil.  Frequent  bathing,  followed  by  ointments  of  tar, 
sulphur,  or  naphthol,  gives  relief. 

DERMATITIS  HERPETIFORMIS. 

(Herpes  Gestationis,  Duhring's  Disease.) 

Definition, — A  chronic  inflammatory  disease,  characterized 
by  multiform  lesions  which  form  in  groups,  and  which  are 
associated  with  intense  itching. 

Etiology. — Women  are  more  commonly  affected  than 
men.  Pregnancy,  lactation,  and  menstrual  disorders  seem 
to  exert  a  predisposing  influence. 

Symptoms.  Mythematous  Form. — This  is  characterized  by 
the  appearance  in  crops  of  erythematous  patches  which  are 
associated  with  considerable  itching. 

Papular  Form. — Groups  of  j)apules  appear  in  crops,  and 
are  frequently  associated  with  erythema,  vesicles  and  scratch- 
marks. 

Vesicular  Form. — Groups  of  irregular-shaped  vesicles  resem- 
bling herpes  appear  in  crops  and  are  often  associated  with 
erythema,  pustules,  and  scratch-marks. 

Pustular  Form. — This  resembles  the  former,  but  the  vesicles 
are  replaced  by  pustules. 


DERIVIATITIS.  469 

Bullous  Form. — Large  irregular-shaped  blebs  appear  in 
crops  and  tend  to  group.  Vesicles  and  patches  of  erythema 
are  also  frequently  present. 

Mixed  Form. — Vesicles,  erythematous  patches,  pustules, 
papules,  and  blebs  appear  in  association,  come  out  in  crops, 
and  are  attended  with  intense  itching. 

In  the  pustular,  bullous,  and  mixed  forms  there  may  be 
marked  constitutional  disturbances. 

Peognosis. — Guardedly  favorable.  The  disease  -runs  a 
chronic  course.     Relapses  are  very  common. 

Treatment. — Tonics  are  generally  indicated.  Lotions  of 
boric  or  carbolic  acid  may  be  employed  to  allay  itching,  and 
may  be  followed  by  a  dusting-jDowder. 

DERMATITIS. 

Definition. — Inflammation  of  the  skin  resulting  from  the 
action  of  some  irritant. 

Dermatitis  Traumatica. — This  term  is  applied  to  inflam- 
mation of  the  skin  resulting  from  traumatism. 

Treatment. — The  removal  of  the  cause  and  the  applica- 
tion of  soothing  remedies  will  usually  suffice. 

Dermatitis  Venenata. — The  term  is  applied  to  inflamma- 
tion of  the  skin  resulting  from  the  application  of  vegetable, 
animal,  or  chemical  irritants.  Notable  examples  of  this  form 
of  dermatitis  are  observed  in  susceptible  people  after  exposure 
to  the  influence  of  poison  ivy  {Rhus  Toxicodendron),  poison* 
oak  (Rhus  Venenata),  or  poison  sumach  (Rhus  Diversiloba). 

Symptoms  of  Rhus-poisoning. — The  afi'ection  resembles 
acute  eczema,  and  may  appear  in  a  few  hours  or  not  until 
the  lapse  of  several  days  after  exposure  to  the  plant.  It  is 
generally  observed  on  the  face  or  hands.  The  part  becomes 
red  and  swollen,  and  soon  minute  papules  and  vesicles  appear. 
It  gives  rise  to  considerable  burning  and  itching.  As  a  rule, 
it  subsides  in  a  few  days,  but  in  patients  with  sensitive  skin 
it  may  linger  for  several  weeks. 

Treatment. — The  part  should  first  be  bathed  with  castile 
soap  and  tepid  water,  and  then  treated  with  some  sedative 
lotion  or  ointment.     Black  wash  may  be  dabbed  on,  and  zinc 


470       DISEASES   OP  THE   SKIN   AND   ITS  APPENDAGES. 

ointment  subsequently  applied ;  or  a  saturated  solution  of  boric 
acid  may  be  followed  by  zinc  ointment.  When  there  is  marked 
itching  a  weak  solution  of  carbolic  acid  (3j  to  Oj.)  is  useful. 
The  fluid  extract  of  grindelia  robusta  has  been  highly  recom- 
mended ;  it  may  be  applied  in  the  strength  of  half  an  ounce 
to  a  pint  of  water. 

Dermatitis  Calorica. — This  term  is  applied  to  the  inflamma- 
tion of  the  skin  resulting  from  extreme  heat  or  cold.  Pernio, 
or  chilblain,  is  characterized  by  redness,  swelling,  intense 
burning  and  itching,  and  results  from  a  sudden  change  from 
a  low  temperature  to  a  high  temperature.  Frost-bite  is  char- 
acterized by  congelation  ;  the  part  is  of  a  dull-white  color  and 
is  anaesthetic ;  subsequently  inflammation  or  gangrene  develops. 

Burns  and  scalds  result  from  the  application  of  heat,  and 
are  divided  into  degrees  according  to  the  depth  to  which  the 
destructive  process  extends. 

Tkeatment. — In  pernio,  or  chilblain,  the  part  should  first 
be  rubbed  with  snow  or  bathed  in  ice-water  until  the  circula- 
tion is  re-established  ;  and  then  an  application  made  of  nitrate 
of  silver  (gr.  v  to  the  ounce  of  distilled  w^ater)  or  of  tincture 
of  iodine. 

In  superficial  buryis  or  scalds  one  of  the  following  remedies 
may  be  ajjplied  :  Phenol  sodique,  carron  oil  (equal  parts  of  lin- 
seed oil  and  lime-water)^  powdered  bicarbonate  of  sodium,  or: — 

^   Acidi  carbolic,  gr.  viij  ; 

Yaselin.,  "gi}. — M.     (Bellvue  Hospital,.) 
Sig. — Spread  on  lint  and  apply  where  the  skin  is  broken. 

Dermatitis  Medicamentosa. — This  term  is  applied  to  the 
various  cutaneous  eruptions  which  follow  the  internal  use  of 
certain  drugs. 

Belladonna  or  Atropia. — These  drugs  produce  a  diffuse 
erythematous  rash  resembling  that  of  scarlet  fever,  but  it 
lacks  the  punctiform  character  of  the  latter.  It  usually  ap- 
pears on  the  face,  neck,  and  chest,  and  is  associated  with  dry- 
ness of  the  throat,  rapid  pulse,  and  if  the  dose  has  been  large, 
dilated  pupils. 

Oubebs. — This  drug  sometimes  produces  an  erythema  asso- 
ciated with  minute  papules. 


ECtHYMAi  471 

Copaiba. — The  rash  may  be  macular,  papular,  or  like  that 
of  urticaria. 

Bromide  of  Potassium. — The  eruption  resembles  acne  and 
consists  of  papules  and  pustules. 

Iodide  of  Potassium. — The  eruption  may  be  erythematous, 
papular,  pustular,  urticarial,  or  purpuric.  The  most  common 
eruption  resembles  acne,  but  the  lesions  are  bright-red  in  color 
and  widely  distributed  over  the  surface  of  the  body. 

Arsenic.  — The  eruption  may  be  erythematous,  papular, 
vesicular,  or  pustular. 

Antipyrin. — This  drug  not  infrequently  produces  a  wide- 
spread papular  eruption. 

Quinine. — The  rash  is  usually  erythematous,  though  an 
urticarial  eruption  has  been  observed. 

Salicyl  Compounds. — The  eruption  is  usually  erythematous 
or  urticarial. 

Borax. — This  drug  occasionally  produces  an  eruption  resem- 
bling psoriasis. 

Chloral. — The  eruption  is  usually  erythematous  or  urticarial. 

Dermatitis  Exfoliativa. 

This  is  a  rare  affection,  characterized  by  diffuse  redness  of 
the  skin,  high  fever  and  its  associated  phenomena,  and  des- 
quamation. It  is  interesting  from  its  close  resemblance  to 
scarlet  fever,  from  which  it  may  be  distinguished  by  the  history 
and  the  absence  of  sore  throat,  and  a  "  strawberry"  tongue. 

ECTHYMA. 

Definition. — An  inflammatory  affection,  characterized  by 
the  appearance  of  discrete,  flat  pustules,  which  vary  in  size 
from  a  pea  to  a  five-cent  piece,  and  which  are  surrounded  by 
a  distinct  red  areola. 

Etiology. — Male  sex,  middle  life,  bad  hygiene,  and  de- 
bility are  predisposing  factors. 

Symptoms. — Flat,  yellow  pustules  appear  in  crops.  They 
are  surrounded  by  a  distinct  red  areola  and  soon  dry  up,  form- 
ing reddish-brown  crusts.     Slight  excoriation  and  pigmeuta- 


472       DISEASES   OF  THE   SKIJST   AND   ITS   APPENDAGES. 

tion  sometimes  remain  after  the  separation  of  the  crusts. 
Subjective  phenomena  are  usually  absent. 

Diagnosis, — The  acute  course,  the  absence  of  ulceration, 
and  the  absence  of  history  and  of  associated  symptoms  of 
syphilis  will  separate  it  from  the  pustular  syj)hilide. 

Impetigo. — In  this  affection  the  lesions  are  not  flat ;  they  are 
not  distinctly  inflammatory ;  and  the  crusts  are  light  yellow, 
not  reddish-brown.  Impetigo  occurs  most  frequently  in  child- 
ren, who  may  be  quite  robust. 

Peognosis. — Favorable. 

Treatment.  —  Constitutional  treatment  is  generally  re- 
quired. Such  tonics  as  iron,  quinine,  strychnine,  and  cod- 
liver  oil  are  often  idicated. 

Local  Treatment. — The  crusts  should  be  removed  and  some 
stimulating  ointment  applied,  as  the  following : — 

j^^  Hydrarg.  ammoniat.,  gr.  x  ; 
Ung.  zinci  oxidi,  §j. — M. 

PEMPHIGUS. 

Definition. — A  non-contagious  inflammatory  disease,  char- 
acterized by  the  eruption  of  successive  crops  of  bullse  or  blebs. 

Etiology. — Female  sex,  nervous  prostration,  heredity,  and 
injury  to  the  peripheral  nerves  are  predisposing  factors. 

Varieties. — Pemphigus  vulgaris  and  pemphigus  foliaceus. 

Pemphigus  Vulgaris. — This  form  usually  runs  a  chronic 
course  and  is  characterized  by  successive  crops  of  blebs,  vary- 
ing in  size  from  a  small  pea  to  a  large  walnut.  They  are 
thoroughly  distended  with  fluid,  which  is  at  first  clear  but 
subsequently  turbid.  As  a  rule,  they  do  not  rupture,  but  dis- 
appear in  the  course  of  five  or  six  days,  their  contents  being 
gradually  absorbed.  After  absorption  a  thin  pellicle  remains, 
which  dries  and  is  subsequently  detached,  leaving  behind  a 
slightly  pigmented  spot.  No  part  of  the  body  is  exempt ;  and 
as  one  set  of  blebs  disappears,  new  ones  rapidly  develop,  and 
so  the  disease  continues  for  many  years. 

In  severe  cases  there  may  be  considerable  itching  and  burn- 
ing attending  the  eruption. 


IMPETIGO.  473 

Pemphigus  Foliaceus. — This  rare  and  grave  form  of  pem- 
phigus is  characterized  by  crops  of  blebs,  which  are  flaccid  and 
filled  with  a  turbid  fluid  almost  from  the  beginuing.  They 
soon  rupture  and  form  thick  crusts,  which  separating  leave 
behind  red  weeping  surfaces.  The  crops  follow  each  other  in 
rapid  succession,  and  at  times  the  whole  body  may  be  covered 
with  blebs  and  scabs.  The  disease  may  last  several  years, 
death  ultimately  resulting  from  exhaustion. 

Diagnosis.  Bullous  Syphiloderm. — The  history,  the  asso- 
ciated symptoms  of  syphilis,  the  thick,  yellow,  stratified  crusts, 
and  the  underlying  ulceration  wall  serve  to  separate  this  aifec- 
tion  from  pemphigus. 

Impetigo  Contagiosa. — The  acute  course,  the  contagious 
and  auto-inoculable  character  of  the  aifection,  and  the  umbili- 
cation  of  the  blebs  will  separate  impetigo  contagiosa  from 
pemphigus. 

Prognosis. — The  prognosis  should  be  guarded.  Pemphi- 
gus vulgaris  runs  a  long  course  and  is  often  intractable.  Pem- 
phigus foliaceus  often  proves  fatal  through  exhaustion. 

Treatment. — The  diet  should  be  nutritious,  but  carefully 
adapted  to  the  stomach.  The  patient  should  be  placed  under 
the  best  hygienic  conditions.  Tonics  like  iron,  quinine,  phos- 
phorus, cod-liver  oil,  and  strychnine  are  usually  indicated. 
In  many  cases  arsenic  is  a  valuable  remedy. 

Local.  Treatment. — The  blebs  may  be. punctured  and 
subsequently  dressed  with  zinc  ointment. 

IMPETIGO. 

Definition. — An  acute  inflammatory  disease,  characterized 
by  an  eruption  of  discrete  pustules  varying  in  size  from  a  pea 
to  a  cherry. 

Etiology. — The  exciting  cause  is  unknown.  It  is  most 
coii?monly  observed  in  children. 

Symptoms. — A  pustular  eruption  appears  generally  on  the 
face  and  ^stremities.  The  pustules  are  generally  few  in  num- 
ber, and  are  discrete,  tense,  and  surrounded  by  a  slight  areola. 
In  a  few  days  they  dry  up  and  form  thin  yellowish-brown 


474       DISEASES   OF   THE  SKIN   AND   ITS   APPENDAGES. 

erustSj  which  soon  drop  off  and  leave  behind  a  normal  surface. 
Subjective  phenomena  are  absent. 

Diagnosis.  Ecthyma. — This  affection  occurs  most  fre- 
quently in  debilitated  adults;  the  pustules  are  flat,  sur- 
rounded by  a  distinct  areola,  and  dry  to  brown  crusts  which 
separate  and  leave  a  pigmented  excoriated  surface. 

Impetigo  Contagiosa. — As  the  name  implies,  this  affection  is 
contagious  and  is  auto-inoculable ;  its  pustules  are  flat  and  um- 
bilicated,  and  dry  up  and  form  lamellated,  thin,  yellow  crusts. 

Peognosis. — Favorable.  It  terminates  spontaneously  in  a 
few  days  or  a  week. 

Treatment. — Open  the  pustules  and  apply  some  simple 
protective  ointment,  like  that  of  oxide  of  zinc. 

OIPETIGO  CONTAGIOSA. 

Definition. — An  acute  contagious  inflammatory  disease, 
characterized  by  flat,  yellowish  blebs  which  dry  up  and  form 
thin,  yellow,  lamellated  crusts. 

Etiology. — Its  exciting  cause  is  unknown.  It  is  most 
frequently  observed  in  debilitated  children. 

Symptoms. — The  eruption  is  most  frequently  observed  on 
the  face  and  extremities  ;  it  generally  appears  in  crops,  and  is 
at  first  vesicular.  The  vesicles  grow,  and  are  soon  converted 
into  flat,  umbilicated  pustules  which  vary  in  size  from  a  pea 
to  a  large  walnut.  They  have  a  slight  red  areola.  Itching 
is  slight  or  entirely  absent.  In  some  cases  there  is  moderate 
fever  with  its  associated  phenomena.  In  a  few  days  the  blebs 
dry  up  and  form  thin,  yellow,  lamellated  crusts  which  separat- 
ing leave  a  slightly  excoriated  surface.  The  disease  is  con- 
tagious, and  the  lesions  are  auto-inoculable. 

Diagnosis.  Eczema. — In  this  disease  the  pustules  are 
deeper,  more  confluent,  excite  intense  itching,  and  are  asso- 
ciated with  inflammation  and  infiltration  of  the  surrounding 
skin. 

Simple  Imjjetigo. — This  affection  is  not  contagious  or  auto- 
inoculable  ;  the  pustules  are  tense,  not  flat  or  umbilicated ; 
and  the  subsequent  crusts  are  yellowish-brown  and  are  not 
followed  by  excoriation. 


MILIAEIA.  i75 

Peognosis. — Favorable.  It  terminates  spontaneously  in  a 
few  days  or  weeks. 

Treatment. — A  slight  stimulating  ointment  like  the  fol- 
lowing is  sometimes  useful : — 

^   Hydrarg.  ammon.,  gr.  x-xx; 
Adipis,  5j.— M. 
Sig. — Apply  to  the  surface  after  removal  of  the  crusts. 

MILIARIA. 

(Prickly  Heat.) 

Definition. — An  acute  inflammatory  disease  of  the  sweat- 
glands,  characterized  by  a  discrete  eruption  of  minute  papules 
and  vesicles. 

Etiology. — Childhood  and  high  temperature  are  the  prin- 
cipal predisposing  causes. 

Symptoms. — The  eruption  generally  appears  on  the  trunk, 
and  consists  of  minute  closely-aggregated  red  papules  or  clear 
vesicles.  The  lesions  are  discrete,  and  excite  some  burning 
and  itching.     It  is  generally  associated  with  free  perspiration. 

Diagnosis. — Eczema  papillosum  diifers  from  miliaria  in 
that  the  papules  are  larger,  appear  more  gradually,  disappear 
more  slowly,  and  excite  intense  itching. 

Eczema  vesiculosum  differs  from  miliaria  in  that  the  vesicles 
are  large,  disappear  more  slowly,  show  a  tendency  to  break, 
and  are  associated  with  marked  itching. 

Sudamen  differs  from  miliaria  in  that  it  lacks  all  inflamma- 
tory characteristics. 

Prognosis. — Favorable.  Obstinate  cases  may  persist  for 
several  weeks. 

Treatment. — The  general  health  may  require  attention. 
The  diet  should  be  light,  and  easily  assimilable.  Constipation 
should  be  relieved  by  saline  laxatives.  Locally,  a  simple 
dusting-powder  is  generally  all  that  is  required. 

^  Pulv.  amyli,  ^vj ; 
Zinc,  oxidi,  ^iss ; 

Pulv.  camph.,  ^ss.— M.     (Hakdaway.) 
Sig. — Dusting-powder. 


476       DISEASES   OF   THE  SKIN  AND    ITS   APPENDAGES. 

Or— 

^   Zinc,  catbonat.  prsecip. ,  ^i v ; 

Zinc,  oxidi,  gij  ; 

Glycerini,    f  gij  ; 

Aq.  rosse,  f^viij.— M.     (Tilbury  Fox.) 
Sig. — Apply  locally. 

ALBINISM. 

Definition. — A  congenital  deficiency  of  pigment. 

Etiology, — Beyond  heredity,  no  cause  is  known.  Partial 
albinism  is  more  common  in  the  negro. 

Symptoms. — In  complete  albinism  the  skin  is  white ;  the 
hair  is  thin,  soft,  and  very  light  in  color ;  the  pupils  appear 
red,  the  eyes  are  very  sensitive  to  light,  and  the  iris  and 
choroid  are  deficient  in  pigment. 

VITILIGO. 

(Leucodenna.) 

Definition. — An  acquired  cutaneous  affection,  character- 
ized by  milk-white  patches  which  are  surrounded  by  areas  of 
increased  pigmentation. 

Etiology. — The  disease  seems  to  be  more  common  in  the 
tropics  and  in  the  colored  race.  The  condition  probably 
results  from  disturbed  innervation. 

Symptoms. — Milk-white  spots  appear  on  the  body  and 
grow  very  slowly ;  their  borders  usually  reveal  an  increase  of 
the  normal  pigment.  Apart  from  the  absence  of  pigment  the 
skin  is  normal. 

Diagnosis.  Morphoea. — The  initial  hypersemia  and  the 
subsequent  atrophy  of  the  skin  will  serve  to  distinguish 
morphoea  from  vitiligo. 

Ancestheiie  Leprosy. — The  subjective  symptoms,  the  atrophy 
of  the  tissues,  and  the  ansesthesia  will  separate  leprosy  from 
vitiligo. 

Prognosis.  —  Unfavorable;  the  disease  usually  persists 
through  life. 

Treatment. — Tonics  and  local  stimulants  may  be  tried. 
Among  the  latter,  electricity,  blisters,  and  irritating  ointments 
have  been  recommended,  arsenic  is  recommended. 


CANITIES — ATROPHY   OF   THE   HAIR.  477 

CAKITIES. 

Definition. — Grayness  of  the  hair. 

Etiology. — Local  grayness  may  be  coDgenital,  or  result 
from  some  disturbaDce  of  innervatiou,  as  in  neuralgia  of  the 
supraorbital  nerve.  As  a  general  condition  it  is  usually  an 
expression  of  senility,  although  it  occasionally  develops  very 
early  in  life.  Profound  emotional  disturbances  sometimes 
induce  an  abrupt  development  of  canities. 

Prognosis. — The  condition  is  permanent,  and  treatment  is 
of  no  avail. 

ATROPHY  OF  THE   SKIN, 

Etiology. — Atrophy  of  the  skin  occurs  under  several  con- 
ditions. A  local  atrophy  may  result  from  inflammation  or 
injury  of  a  nerve-trunk  ;  in  these  cases,  the  wrinkles  are  absent, 
the  skin  is  thin,  smooth,  and  shiny,  and  there  is  often  intense 
burning  in  the  part  ("  glossy  skin").  Atrophy  is  also  ob- 
served in  leprosy,  morphcea,  and  scleroderma. 

Universal  atrophy  of  the  skin  results  from  senility,  and 
very  rarely  as  an  idiopathic  condition.  Sometimes  the  atrophy 
occurs  in  lines  or  spots  (strice  et  maculoe  atrophicce)  as  an 
idiopathic  condition,  or  as  the  result  of  stretching  the  skin,  as 
in  the  linece  albicantes  following  pregnancy. 

ATROPHY  OF  THE  HAIR. 

Etiology. — Atrophy  of  the  hair  may  result  from  local 
diseases  which  interfere  with  the  nutrition  of  the  scalp,  such 
as  seborrhoea,  eczema,  ringworm,  etc. ;  or  it  very  rarely  arises 
as  an  idiopathic  condition  without  obvious  cause. 

Prognosis. — When  the  cause  can  be  ascertained  and  re- 
moved, the  prognosis  is  favorable. 

Treatment. — Local  diseases  will  require  appropriate  treat- 
ment. The  general  health  should  be  improved.  Stimulating 
applications  of  mercury,  sulphur,  or  carbolic  acid  are  sometimes 
jiseful. 


478        DISEASES   OF  THE  SKIN   AND   ITS   APPENDAGES. 


ATROPHY  OF  THE  KAILS. 

Etiology. — Occasionally  the  condition  is  congenital,  but 
more  frequently  it  is  acquired,  and  results  from  injury  or  dis- 
ease of  the  nerve-trunk ;  from  some  general  disease,  like  one 
of  the  fevers,  syphilis,  or  cancer ;  or  from  some  disease  of  the 
skin,  as  psoriasis  or  ringworm. 

Symptoms. — The  nails  lose  their  lustre,  cease  to  grow,  and 
become  opaque  and  brittle. 

Prognosis  and  Treatment. — Both  will  depend  on  the 
exciting  cause. 

ALOPECIA. 

(Baldness.) 

Etiology. — (1)  Baldness  may  be  congenital ;  in  these  cases 
it  is  usually  partial.  (2)  It  may  be  an  expression  of  senility ; 
in  which  case  it  generally  begins  on  the  crown  or  brow,  and  is 
associated  with  more  or  less  atrophy  of  the  scalp.  (3)  It  may 
occur  early  in  life,  as  an  idiopathic  aiFection  arising  without 
obvious  cause.  (4)  It  may  result  fi'om  general  diseases,  like 
syphilis  and  the  fevers.  (5)  In  early  life  it  is  often  due  to 
some  local  disease,  especially  seborrhoea. 

Prognosis. — In  congenital,  senile,  and  idiopathic  alopecia 
the  prognosis  is  unfavorable.  In  the  alopecia  of  general  dis- 
eases the  prognosis  is  usually  favorable.  In  alopecia  result- 
ing from  seborrhoea  much  can  be  accomplished  by  persistent 
and  judicious  treatment. 

Treatment. — The  general  health  should  be  improved. 
Frequent  washing  the  head  with  warm  water  and  castile  soap 
is  to  be  recommended.  One  of  the  following  local  stimulants 
may  be  prescribed :  Cantharides,  quinine,  alcohol,  capsicum, 
sulphur,  or  carbolic  acid. 

]^  Quininse  sulph.,  gss; 
Tinct.  cantharidis,  f^j  ; 
Spt.  ammon.  aroniat.,  f^j ; 
01.  ricini,  f^iss  ; 
Spt.  myrcise,  f^vss  ; 
01.  rosmarini,  gtt.v. — M.     (Gerhard.) 


Or— 


ALOPECIA  AEEATA.  479 


^   Tinct.  cantharidis,  f|j  ; 
Acid,  carbnlici,  3j  ; 
01.  ricini,  giss  ; 


Or— 


Spt.  myrcipe, 

Spt.  lavanduloe,  aa  f^ij. — M. 


^   Tinct.  cantharidis,  f'Sij  ; 
Quininse  sulpb.,  gr.  x; 
Glycerini,    f.^ss  ; 
01.  rosmarini,  gtt.v ; 
Spt.  myrciffi,  q.  s.  ad^v. — ^M. 


ALOPECIA  AREATA. 

(Alopecia  Circumscripta.) 

Definition. — Baldness  appearing  in  circnmscribecl  patches 
without  any  obvious  lesion  of  the  skin. 

Etiology. — The  cause  is  unknown.  Some  regard  it  as  of 
parasitic  origin,  while  others  look  upon  it  as  a  neurosis.  It 
is  generally  observed  in  early  adult  life. 

Symptoms. — The  disease  is  characterized  by  the  sudden  or 
gradual  appearance  of  circumscribed  round  patches  of  bald- 
ness. At  first  there  is  no  change  in  the  appeai-ance  of  the 
skin,  but  later  it  may  become  pale  and  atrophied.  Although 
the  scalp  is  the  most  frequent  seat,  it  occasionally  involves 
other  hairy  parts,  as  the  eyebrows,  beard,  etc. 

Diagnosis.  Mingivonn. — Ringworm  is  exceedingly  rare  in 
adults,  and  is  characterized  by  elevated  scaly  patches  through 
which  project  dry,  brittle,  broken  hairs.  If  there  should  be 
any  doubt  in  the  diagnosis,  the  microscope  may  be  employed 
to  detect  the  tricophyton. 

Prognosis. — In  the  majority  of  cases  the  hair  returns 
under  prolonged  and  persistent  treatment.  The  older  the 
patient  the  less  favorable  the  prognosis. 

Treatment. — General  tonics  like  iron,  arsenic,  quinine,  and 
strychnine  are  usually  indicated.  The  local  treatment  should 
be  stimulating  and  consist  in  the  application  of  blisters,  elec- 


480       DISEASES   OF   THE   SKIN   AND   ITS   APPENDAGES. 

tricity,  friction,  rubefacient  liniments,  or  ointments  containing 
chrysarobin,  tar,  sulphur,  or  ammoniated  mercury. 

^  Tinct.  cantharidis, 

Tinct.  capsici,  aa  f^iss  ; 
Olei  ricini,  f^ij  ; 
Alcoholis,  fgvj  ; 
Spts.  rosmarini,  fgij. — M. 

(DuHRiNG  and  Stel wagon.  ) 


Or— 

Or— 


1^  Acid,  chrysophanic. ,  giss ; 
Adipis,  ^ij. — M. 

^  Sulphur,  loti,  giv ; 
01.  cadini,  ^ij  ; 
Adipis,  ^j. — ^M. 

SYCOSIS. 

(Simple  Sycosis,  Folliculitis  Barbae.) 

Definition. — A  non-contagious  inflammatory  disease  of 
the  hair-follicles. 

Etiology. — The  aifection  results  from  local  irritation  and 
the  entrance  of  pyogenic  cocci. 

Symptoms. — The  disease  usually  manifests  itself  on  the 
bearded  region  of  the  face,  and  is  characterized  by  an  aggre- 
gation of  papules  aud  pustules,  each  of  which  is  pierced  by  a 
hair.  When  the  lesions  are  discrete  the  intervening  skin  is 
often  quite  healthy ;  but  when  they  are  close  together  it  is 
often  infiltrated  and  hypersemic.  During  the  papular  stage 
the  hairs  are  not  loose,  but  firmly  attached ;  during  the  pus- 
tular stage,  however,  they  can  be  readily  extracted.  The 
pustules  show  no  tendency  to  rupture,  but  dry  to  yellowish- 
brown  crusts.  Acute  cases  are  associated  with  more  or  less 
burning  and  itching.  If  the  disease  persists,  it  may  lead  to 
extreme  destruction  of  the  hair-follicles  and,  as  a  consequence, 
to  permanent  alopecia. 

Diagnosis.  Eczema. — The  lesions  in  eczema  excite  severe 
itching,  are  not  perforated  by  hairs,  and  are  not  confined  to 
the  hairy  parts. 

Tinea  Sycosis,  oi-  JBarber's  Itch. — The  affection  begins  as  a 


POMPHOLYX.  481 

red  scaly  patch,  and  is  followed  by  the  development  of  large, 
deeply-seated  tubercles.  The  hairs  soon  become  dry,  brittle, 
and  broken  off,  and  can  be  easily  extracted.  In  doubtful 
cases  the  microscope  may  be  employed  for  the  detection  of  the 
tricophyton. 

Prognosis. — The  disease  is  curable  under  prolonged  and 
judicious  treatment.     Relapses  are  very  prone  to  occur. 

Treatment. — In  acute  cases  soothing  applications  are  in- 
dicated ;  thus  the  parts  may  be  dabbed  with  black  wash  or 
a  saturated  solution  of  boric  acid,  and  subsequently  spread 
with  oxide  of  zinc  ointment.  In  chronic  cases  the  crusts 
should  be  removed,  and  the  hairs  cut  close  or  preferably, 
shaved.  It  is  advisable  to  puncture  the  pustules  and  to  ex- 
tract the  hairs,  so  as  to  preserve  the  follicles.  When  the  parts 
are  not  irritable  stimulating  applications  are  useful,  and  one 
of  the  following  may  be  selected  : — 

^  Sulphixr.  prsecip.,  gij  ; 
Ung.  aquse  rosee,  ^j. — M. 
Sig. — Apply  twice  daily. 

Or— 

]^  Ung.  diachyli, 

Ung.  zinc,  oxidl,  aa  ^iss  ; 
Ung.  hydrarg.  ammon.,  giij  ; 
Bismutli.  subnitratis,  giss. — M.     (Kobinson.) 
Sig. — Apply  twice  daily. 

Or— 

^  Ichthyol.,  3j  ; 
Ung.  diachyli,  ^ ) 
Sig. — Apply  twice  daily. 

POMPHOLYX. 

(Dysidrosis.) 

Pompholyx  is  a  very  rare  disease,  usually  observed  in  those 
who  perspire  freely,  and  characterized  by  an  eruption  of 
deeply-seated  vesicles  which  resemble  sago-grains  imbedded 
in  the  skin.  The  vesicles  most  commonly  appear  on  the  hands, 
especially  between  the  fingers,  and  gradually  increase  in  size 
31 


482       DISEASES   OF  THE   SKIN   AND   ITS  APPENDAGES. 

until  they  reach  the  dimensious  of  blebs.  They  show  no 
tendency  to  rupture,  but  dry  up,  and  are  followed  by  exten- 
sive desquamation  of  the  cuticle.  The  eruption  often  excites 
considerable  pain  and  tenderness.  The  disease  usually  dis- 
appears in  the  course  of  a  few  weeks,  but  is  prone  to  recur. 

Treatment. — General  tonics  like  iron,  strychnine,  and 
arsenic  are  often  indicated.  Locally,  sedative  lotions  or  oint- 
ments should  be  employed. 

IiENTIGO. 

(Freckle.) 

Definition. — A  deposition  of  pigment  in  the  form  of 
small,  irregular-shaped  brownish  spots. 

ETiOLOGY.-^Blondes  are  more  subject  to  the  aflPection  than 
brunettes.  Exposure  to  the  sun's  rays  often  serves  as  an 
exciting  cause. 

Symptoms. — Exposed  parts — the  face,  shoulders,  arms,  and 
hands — are  mostly  aifected.  The  patches  vary  in  color  from 
yellow  to  dark  brown,  and  range  in  size  from  a  pin-head  to  a 
pea. 

Prognosis. — Freckles  can  be  removed,  but  they  always 
return. 

Treatment. — One  of  the  best  remedies  is  the  bichloride  of 
mercury  in  solution  or  ointment. 

1^^  Hydrarg.  chlor.  corros.,  gr.  iv; 
Alcohol,  et  aquse,  aa  ad  :§iv. — M. 
Sig. — Apply  twice  daily. 

CHLOASMA. 

Definition. — An  abnormal  deposition  of  pigment  in  the 
form  of  large  brown  or  liver-colored  patches. 

Etiology. — It  may  result  from  the  application  of  external 
irritants ;  from  general  diseases  like  malaria  and  Addison's 
disease;  or  from  affections  of  the  uterus,  as  pregnancy, 
tumors,  etc. 

Symptoms. — The  affection  consists  in  the  appearance — 
especially  on  the  face — of  large,  round,  or  irregular-shaped 


KERATOSIS    PILARIS.  483 

brownish  or  blackish  patches.     Apart  from  the  discoloration 
the  skin  is  normal. 

Diagnosis. — In  Leucoderma  the  periphery  of  the  patches 
is  pigmented,  but  the  central  milk-white  appearance  is  not 
seen  in  chloasma. 

Prognosis. — When  the  cause  can  be  removed  the  prog- 
nosis is  favorable. 

Treatment. — When  possible  the  cause  should  be  removed. 
The  best  local  remedies  are  bichloride  of  mercury  and  sul- 
phur. 

^  Zinci  oxidi,  gr.  iij  ; 

Hydrarg.  ammoniat.,  gr.  iss  ; 
Ol.  theobrom., 
01.  ricini,  aa  ^iiss  ; 

Essent.  roste,  gtt.  x. — M.     (MoNiiSr.) 
Sig. — Apply  to  the  face  night  and  morning. 

KERATOSIS  PILARIS. 

(Lichen  Pilaris.) 

Definition. — Small,  papular  elevations  resulting  from 
hypertrophy  of  the  epidermis  surrounding  the  outlets  of  the 
hair-follicles. 

Etiology. — It  generally  results  from  infrequent  bathing. 

Symptoms. — The  skin,  particularly  on  the  extensor  sur- 
faces of  the  arms  and  legs,  is  the  seat  of  numerous  pin-head 
elevations,  which  have  a  dirty-gray  color  and  are  pierced  by 
hairs.  It  may  excite  some  itching.  Generally  there  are  no 
evidences  of  inflammation,  but  sometimes  a  few  red  papules 
or  even  pustules  result  from  irritation. 

Diagnosis. — In  Cutis  Ansenna,  or  goose-flesh,  the  lesions 
are  transient  and  have  the  color  of  normal  skin. 

Prognosis. — Favorable. 

Treatment. — In  most  cases  nothing  will  be  required  be- 
yond frequent  bathing  with  soap,  followed  by  friction  of  the 
skin.  In  obstinate  cases  some  simple  ointment  may  be  ap- 
pbed  after  bathing. 


484       DISEASES   OF  THE  SKIN   AND   ITS  APPENDAaES. 

MOLLUSCUM  EPITHELIAI.E. 

(Molluscum  Contagiosum,  MoUuscum  Sebaceum.) 

Definition. — A  cutaneous  aflfection,  characterized  by  the 
appearance  of  discrete  wax-like  elevations  ranging  in  size  from 
a  pin-head  to  a  pea,  and  varying  in  color  from  white  to  rose- 
pink. 

Etiology. — The  disease  is  generally  observed  in  children, 
and  frequently  affects  several  members  of  the  same  household, 
school,  or  asylum.     It  is  probably  contagious. 

Symptoms. — Small  white  or  pale-pink,  wax-like  elevations 
appear,  especially  on  the  face.  They  are  always  discrete  and 
rarely  abundant.  The  centre  of  the  elevation  is  depressed 
and  reveals  a  dark  spot  which  corresponds  to  the  aperture  of 
the  follicle.  At  first  the  lesions  are  quite  firm,  but  as  they 
grow  old  they  become  soft.  When  firmly  squeezed  they 
exude  a  soft,  cheesy  material.  After  remaining  for  several 
weeks  they  break  down  or  undergo  slow  absorption. 

Diagnosis. — The  color,  the  wax-like  appearance,  the  um- 
bilication,  and  the  central  aperture  are  the  diagnostic  features. 

Prognosis. — Favorable,  although  the  disease  may  run  a 
protracted  course  of  months  or  years. 

Treatment. — General  tonics  like  iron,  strychnine,  and 
arsenic  are  often  indicated.  The  lesions  should  be  incised, 
the  contents  expressed,  and  their  bases  touched  with  nitrate  of 
silver ;  ointments  of  mercury  and  sulphur  have  also  been  rec- 
ommended. 

CALLOSITAS. 

(Callus,  Keratoma,  Tylosis.) 

Definition. — A  thickened,  horny  condition  of  the  skin 
resulting  from  hypertrophy  of  the  corneous  layer  of  the  epi- 
dermis. 

Etiology. — Constant  irritation  from  friction  or  pressure  is 
the  chief  cause ;  hence  it  is  frequently  seen  on  the  feet  from 
the  rubbing  of  shoes,  and  on  the  hands  from  the  friction  of 
tools. 


CLAvus.  485 

Symptoms. — The  condition  is  characterized  by  the  appear- 
ance of  hard,  thickened,  grayish  masses,  which  gradually 
merge  into  healthy  skin.  The  soles  and  palms  are  the  parts 
most  frequently  affected.  When  slight  it  causes  little  incon- 
venience, but  occasionally  it  becomes  fissured  and  painful. 

Prognosis. — It  yields  rapidly  to  treatment  when  the  cause 
is  removed. 

Treatment. — When  excessive  the  parts  should  be  soaked 
and  the  thickened  epidermis  pared  off.  One  of  the  best  reme- 
dies for  softening  the  horny  overgrowth  is  salicylic  acid ;  it 
may  be  applied  in  the  form  of  a  plaster  or  in  collodion. 

^  Acid,  salicylic,  3j  ; 
Collodii,  f5j.— M. 
Sig. — Apply  night  and  morning. 

CLAVUS. 

(Corn.) 

Definition. — Clavus  is  a  circumscribed  thickening  of  the 
epidermis  usually  appearing  on  the  feet. 

Etiology. — Corns  generally  result  from  the  friction  of  ill- 
fitting  shoes. 

Symptoms. — Small,  circumscribed,  horny  elevations  appear 
upon  the  feet  and  often  excite  severe  pain.  When  bathed  in 
perspiration  they  become  more  or  less  macerated,  and  in  this 
condition  constitute  the  so-called  soft  corn. 

Treatment. — A  radical  cure  requires  the  use  of  well- 
fitting  shoes.  The  corns  may  be  removed  by  soaking,  paring, 
and  the  application  of  some  mild  caustic  like  salicylic  acid. 

^  Acid,  salicylic,  gr.  xxx  ; 
Tinct.  iodi,  vcix ; 
Ext,  cannabis  ind. ,  gi\  x  ; 
Collodii,  f^ss.— M. 
Sig. — Apply  night  and  morning  for  several  days,  and  then  soak 
in  hot  water. 


486       DISEASES   OF   THE   SKIN   AND   ITS   APPENDAGES. 

cor:ntj  cutaneum. 

(Cutaneous  Horn.) 

Definition. — A  circumscribed,  projecting  outgrowth  re- 
sulting from  hypertrophy  of  the  epidermis. 

Symptoms. — Horns  generally  appear  on  the  face,  scalp,  or 
penis,  and  are  usually  observed  in  the  old.  They  consist  of 
dry,  rough,  horny,  more  or  less  conical  projections,  which  vary 
in  length  from  a  few  lines  to  several  inches. 

Peognosis. — Favorable. 

Treatment. — The  horn  should  be  excised  and  the  base 
subsequently  cauterized. 

VERRUCA. 

(Wart.) 

Definition. — A  wart  is  a  circumscribed  elevation  result- 
ing from  hypertrophy  of  the  papillse  and  epidermis. 

Etiology. — The  cause  is  obscure.  A  bacterial  origin  has 
been  suggested.  They  are  most  frequently  observed  in 
children. 

Symptoms. —  Ven-uca  Vulgaris,  or  common  wart,  is  gener- 
ally observed  on  the  hands  of  children.  It  consists  of  a  firm, 
circmnscribed  elevation,  varying  in  size  from  a  millet-seed  to 
a  pea. 

Verimca  'plana,  or  flat  wart,  is  a  circumscribed,  flat,  pig- 
mented elevation  usually  observed  on  the  backs  of  old  people. 

Verruca  Filifonnis. — This  is  a  thread-like  overgrowth,  and 
is  generally  observed  on  the  soft  parts,  like  the  face  and  neck. 

Verruca  Digitata. — This  form  is  made  up  of  numerous 
branches,  and  is  generally  observed  on  the  scalp. 

Verucca  Acuminata,  or  Venereal  Wart. — This  appears  in 
grouj^s  about  the  genitalia.  It  is  soft,  red  in  color,  and  highly 
vascular.  It  may  be  dry  or  moist  according  to  its  location; 
the  latter  condition  often  gives  rise  to  a  peculiarly  offensive 
odor. 

Treatment. — Ordinary  warts  may  be  removed  by  ex- 
cision, caustics,  or  electrolysis. 


ICHTHYOSIS.  487 

Venereal  warts  should  be  bathed  in  some  antiseptic  solution 
and  subsequently  dusted  with  calomel,  iodoform,  or  boric  acid. 

NJEVUS  PIGIVIENTOSUS. 

(Mole.) 

Definition, — A  circumscribed  deposit  of  pigment,  usually 
associated  with  hypertrophy  of  cutaneous  structures. 

Etiology. — Moles  are  usually  congenital. 

Symptoms. — The  neck,  face,  and  trunk  are  favorite  locali- 
ties. The  nsevi  vary  in  number  from  one  to  several  hundred ; 
in  size,  from  a  millet-seed  to  a  filbert ;  and  in  color,  from  yel- 
low to  black.  When  the  surface  is  smooth,  the  growth  is 
termed  ncevus  spilus  ;  when  the  surface  is  covered  with  hair,  it 
is  termed  ncevus  pilosus ;  when  the  surface  is  warty,  it  is 
termed  ncevus  vei'rucosus  ;  and  when  there  is  much  overgrowth 
of  connective  tissue,  it  is  termed  ncevus  Ivpomatodes. 

Treatment. — They  may  be  removed  by  excision,  the  ap- 
lication  of  caustics,  or  by  electrolysis. 

ICHTHYOSIS. 

(Fish-skin  Disease.) 

Definition. — A  chronic  affection  characterized  by  dryness, 
thickening  of  the  epidermis,  and  scaliness. 

Etiology. — The  affection  is  often  hereditary  and  is  usually 
detected  in  early  childhood. 

Symptoms.  —  The  skin  is  dry  and  harsh;  the  surface  is 
covered  with  adherent  polygonal  scales ;  and  the  papillae  are 
more  or  less  hypertrophied.  The  term  Ichthyosis  hystrix  is 
applied  to  the  condition  when  there  is  excessive  hypertrophy 
of  the  papillae.  The  extensor  surfaces  of  the  extremities  are 
the  parts  most  involved. 

Diagnosis. — The  absence  of  all  inflammatory  symptoms 
will  separate  ichthyosis  from  squamous  eczema  and  psoriasis. 

Prognosis. — The  disease  is  incurable ;  but  the  patient  can 
be  rendered  comfortable  by  appropriate  treatment. 


488       DISEASES   OF   THE   SKIN   AND   ITS   APPENDAGES. 

TREATMENT. — The  scalcs  may  be  removed  by  alkaline 
baths  or  by  applications  of  green  soap.  The  skin  may  be 
rendered  pliable  by  rubbing  in  some  simple  ointment. 

I^  Sulphuris,  gr.  xxv-1 ; 

Ung.  simp.,  3J. — M.     (Unna.) 
Sig. — Eub  in  at  night. 

ONYCHAUXIS. 

Onychauxis,  or  hypertrophy  of  the  nail,  may  be  congenital, 
or  may  result  from  certain  skin  aifections,  such  as  eczema, 
ringworm,  or  syphilis ;  from  diseases  of  the  nerves,  as  neuritis ; 
or  from  traumatism. 

HYPERTRICHOSIS. 

(Hirsuties.) 

Hypertrichosis,  or  hypertrophy  of  the  hair,  may  be  local  or 
general.  The  term  is  applied  not  only  to  an  excessive  over- 
growth of  hair,  but  to  a  growth  of  hair  in  unusual  localities,  as 
on  the  faces  of  young  women. 

TREATMENT. — The  hair  may  be  removed  temporarily  by 
shaving,  epilation,  or  depilatories.  Permanent  relief  can  only 
be  accomplished  by  electrolysis. 

SCLERODER3IA. 

(Sclerema,  Scleriasis.) 

Definition. — A  pigmented,  rigid,  indurated  condition  of 
the  skin,  occurring  in  circumscribed  patches  or  involving  the 
entire  body. 

Etiology. — The  cause  is  unknown. 

Syjmpto.ms. — The  affection  may  be  diffuse  or  involve  cir- 
cumscribed patches.  It  may  appear  quite  suddenly,  or  develop 
very  gradually  in  the  course  of  months  or  years.  The  skin 
assumes  a  yellowish-brown  color,  becomes  rigid,  indurated, 
and  hide-bound  ;  the  surface  is  unnaturally  dry  and  smooth. 
When  the  condition  is  advanced  the  joints  become  more  or 
less  immobile. 


MORPHCEA — ELEPHANTIASIS.  489 

Prognosis.  —  Guarded.  It  often  recovers  spontaneously 
after  having  persisted  for  a  long  time.  In  other  cases  the  pro- 
cess may  spread  until  the  patient  becomes  almost  helpless. 

Treatment. — Tonics  like  iron,  arsenic,  and  cod-liver  oil 
are  often  indicated.  Locally,  massage,  friction,  electricity, 
and  inunctions  are  recommended. 


MORPHCEA. 

(Addison's  Keloid.) 

Definition. — A  cutaneous  aifection,  characterized  by  cir- 
cumscribed, rounded,  ivory-like  patches,  which  have  hypersemic 
or  pigmented  borders. 

Etiology. — The  cause  is  unknown.  By  many  it  is  re- 
garded as  a  circumscribed  form  of  scleroderma. 

Symptoms. — The  lesions  usually  appear  upon  the  trunk 
and  consist  of  sharply-circumscribed  patches,  which  are  at 
first  slightly  hypersemic.  The  surface  is  smooth  and  resistant 
to  the  touch.  As  the  patch  grows  old  its  centre  becomes  pale 
and  ivory-like,  while  the  periphery  remains  hypersemic  or  be- 
comes pigmented. 

Prognosis. — Guarded. 

Treatment. — The  same  as  scleroderma. 


ELEPHANTIASIS. 

(Elephantiasis   Arabum,    Elephantiasis    Pachydermia,    Barbadoes 

Leg.) 

Definition. — Hypertrophy  of  the  skin  and  subcutaneous 
tissues,  usually  associated  with  lymphangitis,  oedema,  and  pig- 
mentation. 

Etiology. — While  elephantiasis  may  occur  in  any  part  of 
the  world,  it  is  far  more  common  in  the  tropics.  It  is  most 
frequently  observed  in  the  male  sex,  and  rarely  develops 
before  adult  life.  It  results  from  obstruction  of  the  lym- 
phatics, and  the  most  common  cause  of  such  obstruction  is  the 
presence  of  a  parasite — -filaria  sanguinis  hominis. 


490        DISEASES   OF   THE   SKIN   AND   ITS   APPENDAGES. 

Pathology. — Examination  of  the  affected  tissues  reveals 
hypertrophy  of  the  connective  tissue,  oedema,  and  inflamma- 
tion and  dilatation  of  the  lymphatic  vessels. 

Symptoms. — It  usually  begins  with  recurring  attacks  of 
erysipelatoid  inflammation.  The  part  is  red,  swollen,  and 
painful ;  the  lymphatics  may  be  traced  as  branching  red  lines 
beneath  the  skin ;  and  with  these  local  phenomena  there  is 
more  or  less  fever.  After  each  attack  the  part  is  left  a  little 
enlarged,  until  finally  it  presents  the  following  characteristic 
appearance :  it  is  enormously  swollen ;  the  skin  is  thickened, 
roughened,  and  pigmented ;  and  the  papillse  are  unusually 
prominent.  The  regions  generally  affected  are  the  legs  and 
genitals.  In  elephantiasis  of  the  scrotum  {lymph-sGrotwii)  the 
hypertrophied  mass  may  weigh  as  much  as  fifty  or  even  a 
hundred  pounds. 

Prognosis. — In  the  early  stage  the  disease  may  be  ari-ested, 
but  when  fully  established  it  is  incurable. 

Treatment, — The  acute  inflammatory  attacks  should  be 
treated  by  rest  and  the  application  of  sedative  lotions,  like 
lead-water  and  laudanum.  Subsequently  mercurial  inunc- 
tions may  be  employed,  and  the  part  firmly  bandaged  with 
the  view  of  promoting  absorption.  Amputation  may  be  suc- 
cessfully employed  in  lymph-scrotum.  In  elephantiasis  of 
the  limbs  ligation  of  the  main  artery  has  given  somewhat 
encouraging  success.  More  recently  galvanism  has  given  very 
good  results. 

DERMATOLYSIS. 

(Pachydermatocele,  Cutis  Pendula.) 

Definition. — A  circumscribed  liypertrophy  of  tlie  skin 
and  subcutaneous  tissues  resulting  in  a  softened  and  pendulous 
condition  of  the  integument. 

Symptoms. — The  part  affected  is  thickened  and  pigmented  ; 
it  is  soft  and  fat-like  to  the  touch  ;  and  when  the  condition  is 
marked,  the  skin  hangs  in  folds.  The  regions  generally 
affected  are  the  shoulders,  arms,  back,  and  buttocks. 

Treatment. — The  redundant  tissue  may  be  removed  by 
excision  or  electrolysis. 


KELOID — FIBROMA.  491 

KELOID. 

(Cheloid,  Kelis.) 

Definition. — A  new  growth  resulting  from  hypertrophy  of 
the  connective  tissue  of  the  coriuni. 

Etiology. — It  generally  results  from  local  injury,  though 
it  is  claimed  that  it  may  arise  spontaneously.  Certain  fami- 
lies and  individuals  are  especially  predisposed.  It  is  more 
frequent  in  the  colored  race. 

Symptoms. — It  begins  as  a  pale-red  nodule,  which  slowly 
increases  in  size  and  sends  out  claw-like  processes.  From  its 
resemblance  to  a  crab  it  has  been  termed  keloid.  It  is  firm, 
elastic,  slightly  elevated,  sharply  defined,  and  ranges  in  size 
from  a  small  bean  to  a  growth  as  large  as  the  hand.  It 
sometimes  excites  pain  and  itching,  but  generally  subjective 
phenomena  are  absent.  The  regions  most  frequently  involved 
are  the  chest  and  back. 

Diagnosis. — Keloid  may  be  distinguished  from  a  hyper- 
trophied  scar  by  the  fact  that  the  latter  does  not  extend  beyond 
the  limits  of  the  injury. 

Prognosis. — The  growth  is  usually  permanent,  and  after 
removal  invariably  returns. 

Treatment. — It  may  be  removed  temporarily  by  excision, 
electrolysis,  or  caustic  pastes. 

FIBROMA. 

(Molluscum  Fibrosum.) 

Definition. — A  circumscribed  overgrowth  derived  from 
the  subcutaneous  connective  tissue. 

Etiology — Early  life  and  heredity  are  predisposing  factors. 

Symptoms — The  -tumors  are  circumscribed  ;  painless  ;  soft 
or  firm  ;  often  multiple ;  range  in  size  from  a  pea  to  a  hen's 
egg ;  and  do  not  impair  the  general  health.  The  overlying 
skin  may  be  normal  in  appearance  or  slightly  hypersemic. 

Prognosis. — They  are  permanent  and  treatment  is  rarely 
indicated. 


492        DISEASES   OF   THE  SKIN   AND   ITS   APPENDAGES. 

ANGIOMA. 

(Naevus  Vasculosus.) 

Definition. — A  new  growth,  composed  of  cavernous  tissue, 
or  a  congeries  of  small  bloodvessels. 

Angioma  Cavernosum. — This  form  is  congenital,  is  com- 
posed of  cavernous  tissue,  and  appears  as  a  circumscribed, 
elevated,  dark-red  tumor,  which  ranges  in  size  from  a  pea  to 
one  as  large  as  the  hand.     It  is  often  lobulated  and  pulsating. 

Angioma  Simplex  {Capillary  Nawus, Port-ivine  Mark). — This 
form  is  also  congenital,  and  is  composed  of  a  congeries  of  ca- 
pillaries. It  is  non-elevated,  bright-red  or  purple-red  in 
color,  and  may  cover  an  area  of  several  inches.  It  is  gener- 
ally found  on  the  face,  and  constitutes  what  is  popularly 
termed  a  mother's  mark. 

Telangiectasis. — This  form  is  acquired,  and  is  composed  of 
dilated  or  newly-developed  capillaries.  It  appears  as  a  bright- 
red  dot  from  which  branch  dilated  capillaries.  It  is  fre- 
quently associated  with  acne  rosacse ;  it  is  also  common  in 
those  of  a  gouty  diathesis  and  in  those  much  exposed  to  the 
weather. 

Treatment. — Cavernous  angiomata  may  be  removed  by 
ligation,  excision,  or  electrolysis.  Simple  angiomata  and  telan- 
giectasis are  best  treated  by  electrolysis. 

XANTHOMA. 

(Vitiligoidea,  Xanthelasma.) 

Definition.  —  A  circumscribed  connective-tissue  new- 
growth  appearing  as  flat  patches  or  tubercles  of  a  yellowish 
color. 

Etiology. — Middle  life  and  female  sex  are  general  pre- 
disposing factors.  Hepatic  disorders,  especially  obstructive 
jaundice,  seem  to  exert  a  decided  predisposing  influence. 

Symptoms. — There  are  two  forms :  Xanthoma  planum, 
which  generally  appears  about  the  eyelids  and  consists  of 
smooth,  circumscribed,  slightly  elevated,  buif-colored  patches ; 
and  Xanthoma  tuberosum^  which   may  appear  on  the  neck. 


LUPUS   ERYTHEMATOSUS.  493 

shoulders,  trunk,  or  extremities,  and  consists  of  small,  elastic, 
and  yellowish-colored  nodules. 

Treatment. — These  growths  may  be  removed  by  excision, 
electrolysis,  or  caustics. 

LUPUS  ERYTHEMATOSUS. 

(Seborrhoea  Congestiva.) 

Definition — Lupus  erythematosus  is  a  new-growth  result- 
ing from  a  cellular  infiltration  of  the  skin,  and  characterized 
by  circumscribed,  red  patches  which  are  more  or  less  covered 
with  yellowish-gray  adherent  scales. 

Etiology. — Middle  life  and  female  sex  are  predisposing 
factors.  It  frequently  arises  from  disorders  of  the  sebaceous 
glands,  as  seborrhoea  or  acne. 

Pathology. — By  many  it  is  regarded  as  a  chronic  derma- 
titis which  originates  in  the  sebaceous  glands. 

Symptoms. — The  disease  usually  manifests  itself  on  the 
face,  in  the  region  of  the  nose,  and  appears  as  small,  red, 
slightly  elevated  papules,  which  are  more  or  less  scaly.  An 
erythematous  patch  is  gradually  formed  by  the  coalescence  of 
these  papules.  The  periphery  of  the  patch  is  elevated  and 
sharply  defined,  while  the  centre  is  depressed  and  atrophied. 
The  ducts  of  the  sebaceous  glands  are  dilated  and  often  filled 
with  sebum.  The  disease  spreads  very  slowly,  shows  no  ten- 
dency to  ulceration,  and  rarely  excites  any  subjective  symptoms. 

Diagnosis. — The  location,  the  sharply-defined  red  patch 
with  an  elevated  margin  and  depressed  centre,  the  slight  scali- 
ness,  the  dilated  sebaceous  ducts,  the  chronic  course,  and  the 
absence  of  ulceration  are  the  diagnostic  features. 

Lupus  Vulgaris. — This  aifection  begins  earlier  in  life,  is 
characterized  by  tubercles  and  ulceration,  and  lacks  involve- 
ment of  the  sebaceous  glands. 

Prognosis. — Favorable  under  prolonged  and  judicious 
treatment. 

Treatment. — General  tonics  like  iron,  arsenic,  phos- 
phorus, and  cod-liver  oil  are  often  indicated. 

Local  Treatment. — In  many  cases  mild  applications 
accomplish  the  most  good.     Much    benefit  is  often  derived 


494       DISEASES   OF   THE  SKIN   AND   ITS   APPENDAGES. 

from  washing  the  part  thoroughly  with  green-soap  and  alcohol 
for  a  few  days  and  then  applying  the  following  lotion : — 

^   Zinc,  sulphatis, 

Potassi  sulpliidi,  aa  ^ij  ; 
Aqufe,  fgiij  ; 

Alcoholis,  f5j.— M,     (Duhbing.) 
Sig. — Shake  well,  dab  the  parts  for  fifteen  minutes  twice  daily, 
and  allow  to  dry  on. 

In  sluggish  cases  stimulating  applications  are  useful,  and 
one  of  the  following  may  be  selected : — 

'^  Acid,  salicj-l. ,  gss  ; 
Acid,  lactic,  gss ; 
Eesorciu.,  gr.  xlv ; 
Zinc,  oxid.,  ^ij  ; 
Vaselln.  pur.j'^xvij.— II.     (Broca.) 

Or— 

J^:  Acidi  p5'rogallici,  3j  ; 

Cerati,  ^ix. — M.    (Kaposi.) 
Sig. — Apply  locally. 

In  obstinate  cases,  scarification,  curetting,  or  burning  %vith 
the  galvano-cautery  may  be  employed  with  advantage. 

LUPUS  VULGARIS. 

(Lupus  Esedens.) 

Definition. — A  local  manifestation  of  tuberculosis,  char- 
acterized by  soft  red  tubercles,  which  usually  terminate  in  ul- 
ceration and  scarring. 

Etiology. — Early  life  and  female  sex  are  general  pre- 
disposing factors.  It  is  comparatively  rare  in  this  country, 
but  very  common  in  Austria  and  Germany.  The  exciting 
cause  is  the  tubercle  bacillus. 

Symptoms. — Lupus  vulgaris  most  frequently  manifests  it- 
self on  the  face,  especially  near  the  nose.  It  begins  as  minute, 
deeply-seated,  reddish-broTMi  papules,  which  grow  very  slowly 
until  they  reach  the  dimensions  of  tubercles.  They  are  smooth, 
quite  soft,  and  seldom  painful.  At  this  stage  they  may  either 
undergo  slow  absorption  or,  which  is  more  frequent,  break  down 
and  leave  chronic  ulcers.     The  ulcers  are  shallow,  and  their 


LUPUS   VULGARIS.  495 

edges  are  soft  and  red.  There  is  very  little  discharge.  They 
spread  slowly,  and  may  involve  all  the  soft  parts,  but  the  bone 
is  never  invaded.  While  one  part  of  the  ulcer  is  spreading, 
other  parts  are  being  filled  with  shriv^elled  cicatricial  tissue 
which  in  turn  is  often  the  seat  of  new  tuberculous  nodules. 

Diagnosis.  Epithelioma. — Epithelioma  is  a  disease  of  ad- 
vanced life ;  it  begins  as  a  firm,  wax-like  nodule ;  the  resulting 
ulcer  starts  from  a  single  point ;  its  borders  are  distinctly  ele- 
vated and  hard ;  it  secretes  a  blood-streaked  fluid ;  and  it  is 
often  painful. 

Syphilis — The  age,  history,  associated  evidences  of  syphilis, 
the  rapid  course,  the  deep  ulcers,  the  abundant  offensive  dis- 
charge, and  later  the  involvement  of  the  bones,  are  the  diag- 
nostic features. 

Prognosis. — Very  guarded.  Its  removal  is  often  followed 
by  relapse. 

Treatment. — General  tonics  like  iron,  arsenic,  phos- 
phorus, and  cod-liver  oil  are  usually  indicated. 

Local  Treatment. — The  growth  may  be  removed  by  cauter- 
ization, curetting,  excision,  or  electrolysis.  One  of  the  fol- 
lowing caustic  applications  may  be  employed  : — 

'^  Acid,  arsenosi,  9j  ; 

Hydrarg.  sulphuret.  rub.,  3j ; 
Ung.  simplicis,  5j. — M.     (Hebra.) 
Sig. — Spread  thick  on  cloth,  and  apply  to  the  patch  for  two  or 
three  days,  until  lupus  nodules  and  points  are  blackish  or  destroyed. 

Or— 

1^  Acid,  lactic,  puri,  f.?.— M.     (Wichmank.) 
Sig. — Soak  a  pledget  of  absorbent  cotton  and  apply  to  the  ulcer. 
Cover  with  oil-silk  and  bandage.  Protect  normal  tissue  with  grease. 

Or— 

^i  Acid,  salycilic,  ^ij  ; . 
Adipis  beuzoat.,  3J. — M. 
Sig. — Apply  locally. 

Often  the  best  results  are  obtained  by  curetting  and  subse- 
quently applying  caustics. 

Koch's  tuberculin  has  lately  been  employed  extensively  in 
the  treatment  of  lupus,  but  it  has  not  given  sucli  good  results 
as  were  expected.     After  its  use  most  cases  improve,  many 


496        DISEASES   OF   THE   SKIN   AND   ITS    APPENDAGES. 

relapse,  a  few  recover.      It  seems  best  adapted  to  rapidly- 
spreading  forms  of  lupus. 

SYPHILIS  CUTAIVEA. 

The  secondary  symjjtoms  appear  between  the  first  and  fourth 
month  following  the  cTiancre,  and  are  characterized  by  a  sym- 
metrical arrangement,  a  coppery  color,  polymorphism  (many 
forms  at  the  same  time),  and  an  absence  of  itching.  They  are 
usually  associated  with  certain  general  symptoms,  such  as  sore 
throat,  pain  in  the  bones,  loss  of  hair,  enlargement  of  the 
lymphatic  glands,  and  failure  of  health. 

The  tertiary  symptoms  appear  in  from  six  months  to  several 
years  after  the  primary  sore.  They  are  as  a  rule  localized, 
are  tubercular,  gummatous,  or  ulcerative  in  form,  and  tend  to 
group. 

Macular  S3n?hiloderm. — This  is  a  secondary  manifestation, 
and  consists  in  a  general  eruption  of  dark-red  macules,  vary- 
ing in  size  from  a  millet-seed  to  a  ten-cent  piece. 

Diagnosis.  Measles. — The  absence  of  fever,  of  catarrh,  of 
a  crescentic  arrangement,  together  with  the  history,  will  pre- 
vent an  error  in  diagnosis. 

Papular  Syphiloderm. — This  may  be  an  early  or  late  mani- 
festation, and  is  characterized  by  a  general  eruption  of  large 
or  small,  dull-red  papules.  A  i^w  pustules  are  also  frequently 
present.  It  pursues  a  chronic  course,  finally  disappearing  by 
desquamation,  and  leaving  behind  slight  pigmentation. 

Diagnosis. — The  history,  distribution,  dark  color,  and  the 
presence  of  pustules  will  separate  it  from  keratosis  pilaris, 
papular  eczema,  and  lichen  ruber. 

Tuberculous  SypMloderm. — A  late  manifestation,  charac- 
terized by  a  localized  eruption  of  dark-red  shiny  papules 
varying  in  size  from  a  pea  to  a  large  bean.  By  some  these 
tubercles  are  regarded  as  gummatous  in  character.  They  pur- 
sue a  chronic  course  and  finally  disappear  by  absorption  or 
ulceration.  The  ulcers  thus  formed,  when  single,  are  round, 
punched  out,  and  frequently  covered  with  crusts ;  when  they 
coalesce,  they  form  a  serpiginous  sore  which  pours  forth  a  thick 
yellowish  discharge. 


SYPHILIS   CUTANEA.  497 

Diagnosis.  Lupus  Vulgaris. — This  occurs  in  earlier  life ; 
it  pursues  an  extremely  chronic  course ;  the  ulcer  is  superficial ; 
the  tubercles  are  soft,  and  frequently  redevelop  in  the  scar  tis- 
sue ;  the  secretion  is  scant ;  and  the  bone  is  never  involved. 

Epithelioma. — In  this  affection  the  progress  is  slower  ;  there 
is  only  one  point  of  ulceration ;  the  secretion  is  scanty ;  and 
the  border  is  markedly  infiltrated. 

Bullous  SypMloderm. — This  is  a  late  manifestation,  and  is 
characterized  by  an  eruption  of  well-filled  blebs  varying  in  size 
from  acoffee-bean  toa  walnut.  Thecontents  of  the  blebs  are  puri- 
form.  They  subsequently  form  dark,  conical,  stratified  crusts 
under  which  are  ulcers  pouring  forth  a  thick,  purulent  fluid. 

Diagnosis.  Pemphigus. — The  history,  the  concomitant 
symptoms  of  syphilis,  and  thick,  greenish  crusts  will  serve  to 
distinguish  syphilis  from  pemphigus. 

Gummatous  SypMloderm. — This  appears  as  a  firm,  circum- 
scribed nodule  which  gradually  turns  red  and  softens.  It 
may  disappear  by  absorption,  or  break  down  and  leave  a  deep 
punched-out  ulcer. 

Moist  Papules  {Mucous  Patches). — These  consist  in  sofl  flat 
papules  covered  with  an  offensive,  grayish  secretion.  Heat 
and  moisture  favor  their  development,  so  that  their  favorite 
seats  are  around  the  arms,  the  genitalia,  the  mouth,  and  in 
women  under  the  mamm?e. 

Papulo-squamous  Sypluloderm. — This  may  be  an  early  or 
late  manifestation,  and  is  characterized  by  a  general  erup- 
tion of  small  papules  which  are  more  or  less  scaly,  so  as  to 
resemble  psoriasis. 

Diagnosis. — The  history,  the  slight  scaling,  the  dirty-gray 
color  of  the  scales,  the  dark-red  color  of  the  lesions,  the  espe- 
cial tendency  to  involve  the  palms  and  soles  will  serve  to  dis- 
tinguish syphilis  from  psoriasis. 

Squamous  Eczema. — In  this  affection  the  distribution,  the 
infiltration  of  the  skin,  and  the  marked  itching  will  lead  to 
a  correct  diagnosis. 

Annular  SypMloderm. — In  this  form  the  lesions  consist  of 
circles  or  semi-circles  of  small  dark-red  papules. 

Pustular  SypMloderm. — This  form  usually  appears  within 
the  first  year,  and  is  characterized  by  a  general  eruption  of  small 


498       DISEASES   OF   THE   SKIN   AND   ITS   APPENDAGES. 

or  large,  acuminated  or  flat  pustules  which  finally  dry  up 
and  form  yellowish-brown  crusts.  Large  lesions  leave  super- 
ficial ulcers.  The  term  rupia  is  applied  to  large,  conical, 
stratified  crusts  which  rest  loosely  on  the  ulcerating  basis. 

Diagnosis.  Variola. — Absence  of  syphilitic  history,  the 
shot-like  feel,  the  umbilication,  the  itching,  the  high  fever,  and 
the  acute  course  will  separate  variola  from  syphilis. 

Acne. — This  is  usually  limited  to  the  face  and  shoulders ; 
there  is  no  history  of  syphilis  or  concomitant  symptoms  of 
that  affection. 

Treatment. — The  internal  treatment  consists  in  the  ad- 
ministration of  iodide  of  potassium,  mercurials,  and  tonics. 

^.  Hydrarg.  iodid.,  gr.  j  ; 
Potass,  iodid.,  ^iv  ; ' 
Syr.  sarsaparillee  co., 
Aquae,  aa  f|ij.— M.     (E.  "W.  Tayi,or.) 
Sig. — Teaspoonful  three  times  a  day  after  meals. 

Or— 

^   Hydrai'g.  protiodidi,  gr.  v-x ; 

Ext.  opii,  gr.  v. — M.     (Hardawat. 
rt.  in  pil.  No.  XX. 
Sig. — One  morning  and  evening. 

Local  Treatment. — Papular  eruptions  may  be  washed 
with  mercurial  lotions ;  mucous  patches  may  be  dusted  with 
calomel ;  ulcers  may  be  dressed  with  iodoform. 

LEPROSY. 

(Lepra,  Elephantiasis  Graecorum.) 

Definition. — A  chronic  contagious  disease,  excited  by  the 
bacillus  of  leprosy,  and  characterized  by  tubercular  formations, 
ulcerations,  atrophy,  disturbances  of  sensation,  and  an  in- 
crease or  decrease  of  pigment. 

Etiology. — The  disease  is  contagious,  but  direct  inocula- 
tion is  essential  to  its  transmission.  It  seems  to  be  more 
common  in  hot  climates.  The  exciting  cause  is  the  bacillus 
leprae,  which  closely  resembles  the  tubercle  bacillus. 

Varieties. — There  are  two  varieties  :  Tubercular  leprosy 
and  anaesthetic  leprosy ;  but  the  two  forms  are  often  associated 
in  the  same  patient. 


LEPROSY.  499 

Symptoms. — Certain  prodromes  may  precede  the  outbreak 
of  the  disease,  such  as  malaise,  headache,  chilliness,  depression 
of  spirits,  and  numbness  in  the  parts  to  be  affected. 

Tuberculur  Leprosy. — In  this  form  spots  of  erythema  ap- 
pear on  the  body ;  they  soon  become  pigmented  and  hyper- 
sesthetic,  and  develop  into  tubercles  varying  in  size  from  a  pea 
to  a  walnut.  The  face,  extremities,  and  genitals  are  the  parts 
most  commonly  affected,  but  occasionally  the  mucous  mem- 
branes, especially  of  the  nose  and  throat,  are  invaded.  Ulti- 
mately the  tubercles  may  break  down  and  leave  superficial 
indolent  ulcers.  In  some  cases  a  bullous  eruption  appears 
from  time  to  time.  The  hair,  eyebrows,  and  eyelashes  fall  out, 
the  eyes  become  inflamed,  the  features  distorted,  and  the  voice 
husky.  The  disease  may  last  many  years,  death  finally  result- 
ing from  exhaustion  or  some  intercurrent  disease. 

Ancesthetic  Lejyrosy. — In  this  form  the  peripheral  nerves 
are  invaded  by  the  bacillus  leprae.  The  outbreak  may  be 
preceded  by  numbness,  itching,  or  lancinating  pains.  These 
symptoms  are  followed  by  the  appearance  of  discolored  spots, 
which  are  at  first  associated  with  hypersesthesia,  but  later  more 
or  less  anaesthesia  develops.  The  skin  and  its  appendages 
atrophy,  the  bones  undergo  necrosis,  and  the  phalanges  drop 
off  one  by  one.  In  some  cases  (lepra  alba)  the  skin  is  not 
only  anaesthetic,  but  distinctly  white.  Finally,  when  the  nerves 
are  more  or  less  destroyed  paralysis  results.  The  duration  is 
many  years. 

Prognosis.  — Unfavorable.  A  cure  is  practically  impos- 
sible, though  the  progress  of  the  disease  may  be  stayed  by 
appropriate  treatment. 

Treatment.  —  Sufferers  should  be  isolated.  Tonics  are 
usually  indicated.  Chaulmoogra  oil  and  gurgun  oil,  inter- 
nally and  externally,  have  been  highly  recommended.  Exter- 
nally, chrysarobin,  ichthyol,  or  resorcin  may  be  applied  to  the 
affected  parts. 

'^   Chrysarobin,  gr.  x  -  3j  ; 
^theris  et  alcoholis  ad  q.  s. 
Collodii,  f|j.-M.     (G.  H.  Fox.) 
Kub  the  chrysarobin  with  a  Httle  alcohol  and  ether,  and  add  the 
collodion. 

Sig. — Paint  the  affected  patch  with  a  camel's-hair  brush. 


500       DISEASES   OF   THE  SKIN   AND   ITS  APPENDAGES. 

EPITHELIOMA. 

(Skin  Cancer.) 

Etiology. — Late  life,  heredity,  and  local  irritation  are  the 
predisposing  factors. 

Varieties. — Superficial,  deep-seated,  and  papillomatous. 

Superficial  Epithelioma  {^Rodent  Ulcer). — This  form  usually 
begins  as  a  firm,  circumscribed,  reddish-yellow,  wax-like 
papule.  After  the  lapse  of  several  months  or  years  the  papule 
becomes  scaly,  and  the  removal  of  the  scales  is  followed  by  a 
slight  excoriation,  which  in  turn  becomes  covered  with  a  slight, 
reddish-brown  crust.  The  latter  tends  to  adhere,  and  its  re- 
peated removal  is  followed  by  a  raw  surface,  Avhicli  is  gradu- 
ally converted  into  an  ulcer.  The  ulcer  has  a  prominent  in- 
durated margin ;  its  outline  is  irregular ;  its  base  is  uneven 
and  glazed ;  and  it  exudes  a  sanious  viscid  excretion.  It  is 
not  painful ;  it  does  not  lead  to  enlargement  of  the  neighboring 
lymphatic  glands ;  nor  does  it  cause  impairment  of  the  gen- 
eral health.  It  spreads  very  slowly,  and  sometimes  becomes 
stationary  or  actually  heals.  More  frequently  the  ulceration 
continues  until  it  involves  all  the  tissues  of  the  part,  even  the 
bones.  The  ulcer  generally  appears  on  the  face,  and  in  its 
advance  it  may  destroy  the  nose,  eyes,  or  a  large  portion  of  the 
cranial  bones. 

Deep-seated  Epithelioma. — This  variety  may  begin  as  a 
deep-seated,  red,  shiny  tubercle,  or  it  may  develop  from  the 
superficial  form.  The  ulcer  which  is  ultimately  formed  is 
deep ;  its  base  is  granular ;  its  edges  are  everted,  indurated, 
and  of  a  reddish-purple  color ;  it  secretes  a  blood-stained 
yellow  fluid  ;  it  is  the  seat  of  lancinating  pain  ;  it  causes  en- 
largement of  the  neighboring  glands ;  and  it  sooner  or  later 
induces  the  cancerous  cachexia.  Death  may  result  from  ex- 
haustion, or  more  rarely,  from  hemorrhage  caused  by  ulcer- 
ation of  a  large  bloodvessel. 

Papillomatous  Epithelioma. — This  may  begin  as  a  warty 
excrescence,  or  may  develop  from  one  of  the  preceding  varie- 
ties. It  is  characterized  by  an  ulcerated  surface  from  which 
springs  an  aggregation  of  large,  highly-vascular  papillae.     Be- 


AINHUM — DERMA»ALGIA.  501 

tween  the  papillae  there  are  often  deep-seated  fissures  from 
which  exudes  au  offensive  viscid  discharge.  The  general 
health  is  impaired  and  the  neighboring  glands  are  enlarged. 

Diagnosis.  Lujms  Vulgaris. — Lujdus  begins  in  the  young ; 
the  original  papule  is  soft ;  there  is  often  more  than  one  centre 
of  ulceration ;  the  margins  of  the  ulcer  are  not  hard  and 
everted  ;  the  progress  is  extremely  slow  ;  the  discharge  from 
the  ulcer  is  very  scant,  and  the  bones  are  never  involved. 

Syphilis. — The  history,  the  associated  evidences  of  syphilis, 
the  rapid  progress  of  the  ulceration,  the  abundant  discharge, 
the  absence  of  pain,  and  the  effect  of  treatment  will  suggest 
the  diagnosis. 

Prognosis. — Guarded.  A  thorough  removal  in  the  begin- 
ning of  the  disease  is  often  followed  by  a  permanent  cure. 
When  the  process  is  advanced  the  growth  usually  returns. 

Treatment. — Epitheliomatous  growths  may  be  removed 
by  the  use  of  caustics,  the  cautery,  the  curette,  or  by  ex- 
cision. The  last  is  preferable  when  the  growth  is  small  and 
circumscribed. 

AINHUM. 

Ainhum  is  a  rare  affection,  occurring  chiefly  in  the  colored 
race,  and  characterized  by  the  appearance  of  a  groove  or  fur- 
row at  the  base  of  one  or  more  of  the  toes.  The  groove  deep- 
ens, the  affected  member  becomes  swollen,  and  finally  drops 
off  at  the  point  of  strangulation. 

DERMATALGIA. 

Dermatalgia,  or  neuralgia  of  the  skin,  is  a  rare  affection, 
and  is  characterized  by  paroxysms  of  sharp,  lancinating  pain 
in  the  skin,  which  arise  without  any  change  in  the  local  ap- 
pearance. It  is  most  frequently  observed  in  Avomen  of  a 
neuropathic  tendency,  and  may  arise  from  any  of  the  causes 
which  induce  neuralgia  elsewhere. 

Treatment.- — The  cause  must  be  sought  for  and,  if  pos- 
sible, removed.  Tonics  like  iron,  arsenic,  quinine,  and  phos- 
phorus are  often  indicated.  Locally,  massage  and  electricity 
may  prove  useful.  « 


502       DISEASES   OF   TH0  SKIN   AND   ITS   APPENDAGES. 


PRURITUS. 

Definition. — Pruritus  is  a  functioual  affection,  character- 
ized by  itcliing  which  is  unassociated  with  any  objective  phe- 
nomena. 

Etiology — Pruritus  njay  arise  without  obvious  cause,  as 
the  Pruritus  senilis  observed  in  the  old,  and  the  j^^'uritus 
hiemalis  which  develops  on  the  approach  of  cold  weather  and 
disappears  when  the  weather  becomes  warm. 

Symptomatic  Pruritus. — Pruritus  may  be  a  symptom  of 
many  conditions,  notably  diabetes,  gout,  lithsemia,  hysteria, 
neurasthenia,  and  Bright's  disease. 

Symptoms. — There  is  only  one  symptom  and  that  is  itching ; 
but  as  a  result  of  scratching,  the  part  may  become  hypertemic, 
thickened,  or  the  seat  of  eczema. 

Diagnosis. — Pruritus  must  be  distinguished  from  the  itch- 
ing induced  by  pediculosis,  or  some  local  disease,  like  eczema. 

Prognosis. — This  will  depend  on  the  cause.  When  the 
primary  disease  is  curable  the  prognosis  for  permanent  relief 
is  favorable.  In  other  cases  temporary  relief  only  is  to  be  ex- 
pected. 

Treatment. — Search  should  be  made  for  the  exciting 
cause,  which  should  be  removed,  if  possible.  In  all  cases  the 
urine  must  be  examined  for  sugar,  since  diabetes  is  one  of  the 
most  frequent  causes  of  pruritus.  Among  the  internal  reme- 
dies recommended  for  pruritus  may  be  mentioned  nux  vomica, 
belladonna,  and  pilocarpine.  The  best  local  remedies  are  car- 
bolic acid,  vinegar,  thymol,  chloral-camphor,  boric  acid, 
hydrocyanic  acid,  hot  water,  and  menthol. 

^   Acid,  hydrocyan.  dil.,  f^ij  ; 
Sodii  borat.,  3j  ; 
Aq.  rosse,  f  ^viij.— M.     (Fox.) 
Sig. — Use  locally. 

^  Menthol,  giss ; 

Alcoholis,  f^iv. — M. 
Sig. — Use  locally. 

^  Acid,  carbolic,  f^j-fgij  ; 

Aquse  et  alcohol.,  aa  q.  s.  ad  Oj. — M. 
Sig. — Apply  locally  as  often  as  necessary. 


TINEA  TRICOPHYTINA.  503 

TIKEA  TRICOPHYTESTA. 

(Ringworm.) 

Definition. — A  contagious  disease  excited  by  a  vegetable 
parasite — the  tricophyton. 

Varieties. — On  the  scalp  it  is  termed  Tinea  tonsurans  ;  on 
blie  body,  Tinea  circinata ;  on  the  bearded  region,  Tinea 
sycosis. 

Tinea  Tonsurans, 

This  form  is  observed  almost  exclusively  on  the  scalp  of 
children.  It  is  characterized  by  one  or  more  rounded,  scaly, 
elevated,  grayish-colored  patches  through  which  project  dry, 
brittle,  lustreless,  broken-off  hairs. 

Diagnosis.  Seborrhoea. —  The  patches  are  not  circum- 
scribed ;  the  scales  are  greasy ;  the  hair  is  not  involved  ;  and 
the  microscope  reveals  no  parasite. 

Eczema. — The  patches  are  not  circumscribed  ;  the  hair  is 
not  involved ;  there  is  more  inflammation ;  there  is  marked 
itching ;  and  the  microscope  reveals  no  parasite. 

Alopecia  Areata. — Baldness  is  complete  ;  there  are  no  scales; 
and  the  base  is  smooth  and  shiny. 

Prognosis. — Favorable. 

Treatment.  —  Tonics  are  often  indicated.  The  parts 
should  be  thoroughly  washed  with  soap  and  water,  and  the 
affected  hairs  removed.  The  following  parasiticides  may  be 
employed  in  ointment  or  lotion  ;  mercury,  sulphur,  chrysarobin, 
or  sulphurous  acid. 

^  Acid,  sulphurosi,  f^j  ; 
Aquse,  f^iv. — M, 
Sig. — Apply  several  four  or  five  times  daily. 

Or— 

R     Beta  naphthol,  gr.  xl. ; 
Sulphuris  prtecip.,  3j ; 
Vaselini,  5J. — M. 
Sig. — Rub  into  affected  area  once  or  twice  daily.         (Hardaway.) 


504       DISEASES  OF  THE  SKIN  AND  ITS  APPENDAGES. 

Tinea  Circinata. 

(Ring^ATorm  of  the  Body.) 

This  appears  as  one  or  raore  rounded,  red,  slightly-elevated 
scaly  patches,  which  on  close  examination  reveal  minute 
vesicles  or  papules.  As  the  disease  advances  new  patches 
spring  from  the  periphery  while  the  central  portion  clears  up. 
There  is  often  considerable  itching. 

Diagnosis.  Psoiiasis. — The  marked  scaling ;  the  absence 
of  itching ;  the  tendency  to  involve  the  extensor  surfaces,  es- 
pecially the  knees  and  elbows ;  and  the  absence  of  the  tri- 
cophyton  will  separate  psoriasis  from  ringworm'. 

Eczema. — The  patches  are  ill  defined  ;  do  not  clear  in  the 
centre ;  there  is  more  infiltration  of  the  skin ;  and  there  is  no 
tricophyton. 

Prognosis. — Favorable. 

Treatment. — Tonics  are  frequently  indicated ;  mercury, 
sulphur,  sulphurous  acid,  and  hyposulphite  of  sodium  are 
among  the  best  parasiticides. 

^i.   Sodii  hyposulphit.,3ij  ; 

Aquse,  Y|ij.  — M.     (Dtiheing.  ) 
Sig. — Apply  locally. 

Or— 

^  Hydrarg.  ammoniat.,  gr.  xxx  ; 
Adipis,  ^j. — M. 
Sig. — Apply  locally. 

Tinea  Sycosis. 

(Barber's  Itch,  Sycosis  Parasitica.) 

This  begins  as  a  red  scaly  patch  involving  the  bearded 
region.  Soon  purplish  tubercles  and  pustules  form  around 
the  opening  of  the  hair-follicles,  and  the  hairs  become  lustre- 
less, brittle,  and  loose.      There  is  often  considerable  itching. 

Diagnosis.  Simple  Sycosis. — In  this  the  inflammation  is 
superficial ;  the  hairs  are  not  involved ;  and  the  tricophyton 
is  absent. 


TINEA   VERSICOLOR.  505 

Eczema. — The  tubercles,  the  involvement  of  the  hairs,  and 
the  presence  of  the  tricophyton  will  separate  it  from  eczema. 

Prognosis. — Favorable  ;  unless  treated  actively,  however, 
there  may  be  a  permanent  loss  of  hair. 

Treatment. — The  affected  hairs  should  be  removed,  and 
one  of  the  following  parasiticides  employed  in  lotion  or  oint- 
ment :  Mercury,  sulphur,  or  hyposulphite  of  sodium. 

^   Sodii  hyposulphit.,  ^iij  ; 
Aquse,  figiij. — M. 
Sig. — Apply  locally. 
Or— 

^  Sulphur,  sublimat.,  gij  ; 
Vaselini,  ^ij. 
Sig. — Apply  locally. 

TINEA  VERSICOLOR. 

(Pityriasis  Versicolor.) 

Definition. — A  chronic  affection  excited  by  a  vegetable 
parasite,  the  microsporon  furfur,  and  characterized  by  fawn- 
colored  scaly  patches  which  usually  appear  about  the  chest. 

Etiology. — It  is  a  disease  of  adult  life,  and  is  more  fre- 
quently observed  in  the  debilitated  and  uncleanly. 

Symptoms. — It  appears  usually  on  the  front  of  the  chest  as 
small  round  spots  of  a  pale-yellow  or  fawn  color,  which  slowly 
enlarge,  fuse,  and  form  slightly-elevated  scaly  patches.  Sub- 
jective symptoms  are  generally  absent. 

Diagnosis. — Chloasma  somewhat  resembles  tinea  versi- 
color ;  but  the  former  is  not  often  observed  on  the  trunk,  is 
not  scaly,  and  is  not  associated  with  a  parasite. 

Prognosis. — Fa  vorabl  e. 

Treatment. — The  parts  should  be  frequently  washed  with 
soap  and  water,  after  which  one  of  the  following  parasiticides 
may  be  applied  :  Corrosive  sublimate  (gr.  ij  to  an  ounce  of 
water),  sulphurous  acid,  or  hyposulphite  of  sodium  : — 

^  Sodii  hyposulphitis,  gv  ; 
Glycerini,    f^iij  ; 
Aquoe,  q.  s.  ad  f^v. — M. 
Sig. — Apply  locally. 


506       DISEASES   OF   THE  SKIN   AMD   ITS   APPENDAGES. 

Or— 

^   Hydrarg.  chlor.  corros.,  ^j  ; 
Alcoholis,  f|iv  ; 
Saponis  viridis,  gij ; 

01.  lavandulse,  f^j. — M.     (Van  Harlingen.] 
Sig.-^To  be  rubbed  in  well  uight  and  morning. 

TINEA  FAVOSA. 

(Favus.) 

Definition. — A  contagious  affection  of  the  scalp  excited 
by  the  achorion  SGhonleinii,  and  characterized  by  yellowish, 
cup-shaped  crusts. 

Etiology. — It  is  observed  especially  in  poor,  ill-nourished 
children. 

Symptoms. — The  disease  is  characterized  by  one  or  more 
rounded,  yellow,  cup-shaped  crusts,  through  which  project 
dry,  brittle,  lustreless  hairs.  The  underlying  tissue  is  more 
or  less  atrophied  and  scarred.  It  is  associated  with  some  itch- 
ing and  a  peculiar  musty  odor. 

Diagnosis. — The  yellow,  cup-shaped  crusts,  the  odor,  and 
the  atrophy  of  the  skin  will  separate  it  from  ringworm. 

Prognosis. — Favorable  When  not  treated  early  it  may 
be  followed  by  permanent  baldness. 

Treatment. — The  crusts  should  be  removed  by  oil,  or 
soap  and  water.  The  aifected  hairs  should  also  be  removed. 
The  following  parasiticides  are  efficient :  Mercury,  sulphur, 
chrysarobin,  and  hyposulphite  of  sodium. 

SCABIES. 

(Itch.) 

Definition. — Scabies  is  a  contagious  disease  excited  by  an 
animal  parasite — the  Acaims  Scabiei — and  manifested  by  pap- 
ules, vesicles,  pustules,  burrows,  and  intense  itching. 

Etiology. — The  disease  is  always  acquired  through  inti- 
mate intercourse  with  patients  already  affected. 

Symptoms. — The  disease  manifests  itself  by  intense  itching, 
which  is  associated  with  an  eruption  of  small  papules,  vesicles, 


PEDICULOSIS.  507 

and  pustules.  Among  these  lesions  may  be  found  cuniculi,  or 
burrows  ;  tliese  are  discolored,  dotted,  slightly  elevated  lines 
ranging  from  a  iine  to  half  an  inch  in  length,  and  produced 
by  the  penetration  of  the  female  acarus  and  the  deposition 
of  her  eggs  along  the  passage.  The  parts  most  commonly 
affected  are  the  liands  between  the  fingers,  the  wrists,  the 
axillae,  the  genitalia,  beneath  the  mammae,  and  the  inner 
aspects  of  the  thighs.     The  face  and  scalp  are  never  involved. 

Diagnosis. — Tlie  recognition  of  scabies  rests  on  the  history, 
the  itching,  the  presence  of  burrows,  the  multiformity  of  the 
lesions,  and  their  peculiar  distribution. 

Prognosis. — Favorable. 

Teeatment. — Ointments  of  sulphur,  styrax,  and  napli- 
thol  are  efficient  remedies.  After  a  thorough  bath  the  whole 
body  should  be  anointed  twice  daily  for  three  or  four  days. 
At  the  end  of  this  time  the  bath  should  be  repeated,  and  the 
bed  linen  and  underclothing  changed.  The  infected  clothing 
should  be  sterilized. 

R     Sulphur,  sublimat.,  Sj  ', 
Balsam.  Peruvian.,  3ss; 
Adipis,  gj.— M.     (DuHRiNG.) 
Sig. — Rub  in  thoroughly  twice  daily. 

R     Styracis  liquid.,  3iv; 
Adipis,  ^iss. — M. 

PEDICULOSIS. 

(Phtheiriasis.) 

Pediculosis  Capitis. — This  form  results  from  the  pediculus 
capitis,  or  head-louse,  a  gray  insect  from  one  to  two  milli- 
metres in  length.  The  condition  is  recognized  by  itching  of 
the  scalp  and  the  discovery  of  the  lice  or  their  white  ova,  or 
nits.  Eczematous  lesions  resulting  from  scratching  are  often 
observed. 

Pediculosis  Corporis. — This  form  results  from  the  pediculus 
corporis,  pediculus  vestimenti,  or  body-louse,  a  somewhat 
larger  insect  than   the  head-louse.     The  condition  is  recog- 


508        DISEASES   OP   THE   SKIN   AND   ITS   APPENDAGES. 

nized  by  intense  itching  on  the  covered  parts  of  the  body, 
scratch-marks,  petechise  caused  by  the  bite  of  the  insect,  and 
the  discovery  of  the  lice  on  the  garments. 

Pediculosis  Pubis. — This  form  results  from  the  pediculus 
pubis,  or  crab-louse,  a  minute,  gray,  translucent  insect.  It  is 
found  on  parts  covered  with  short  hair,  as  the  pubes,  axillse, 
eyebrows,  etc. 

Treatment. — In  pediculosis  capitis  the  head  may  be  thor- 
oughly washed  with  coal-oil,  dilute  carbolic  acid  (5j  to  Oj),  or 
tincture  of  cocculus  indicus. 

In  pediculosis  corporis  the  parts  should  be  thoroughly  washed 
and  the  clothes  subjected  to  a  high  temperature.  The  body  may 
be  bathed  in  a  weak  solution  of  corrosive  sublimate. 

In  pediculosis  pubis  an  ointment  of  mercury  is  very  efficient. 


INDEX. 


A. 

Abdomen,  distention  of,  27 
Abscess,  cerebral,  369 
hepatic,  90 
perinephritic,  115 
retropharyngeal,  34 
Acetone,  test  for,  103 
Acetonuria,  causes  of,  103 
Acholia,  82 

Acid,  acetic,  test  for,  22 
butyric,  test  for,  23 
hydrochloric,  test  for,  22 
lactic,  test  for,  22 
Acidity,  degree  of,  24 
gastric,  21 
tests  for,  21 
Acids,  fatty,  in  sputum,  177 
Acne,  458 
Acromegalia,  423 
Addison's  disease,  133 
^gophony,  185 
Agraphia,  408 
Ague,  264 
Ainhum,  501 
Albinism,  476 
Albumin,  tests  for,  102 
Alcoholism,  426 
Alopecia,  478 

areata,  479 
Amimia,  408 
Amoeba  coli,  59 
Ansemia,  127 
cerebral,  358 
essential,  128 
lymphatic,  131 
pernicious,  128 
primary,  128 
symptomatic,  128 
varieties  of,  127 
Ansesthesia,  causes  of,  338 
Analgesia,  causes  of,  339 
Anchylostomum  duodenale,  70 
Aneurism,  aortic,  166 


Angina  pectoris,  165 
Angioma,  cutaneous,  492 
Anidrosis,  448 
Animal  parasites,  68 
Ankle-clonus,  337 
Anorexia,  19 
Anosmia,  171 
Anthrax,  462 
Anuria,  95 
Aortic  aneurism,  166 

valves,  diseases  of,  153,  154 
Apex-beat,  137 

changes  in  the  force  of,  138 
displacement  of,  138 
Aphasia,  407 
Aphonia,  causes  of,  172 
Apoplexy,  cerebral,  359 
pancreatic,  75 
pulmonary,  213 
Appendicitis,  63 
Appetite,  disturbances  of,  19 
Argyll-Robertson  pupil,  346      , 

argyria,  433 
Arhythmia,  144 

Arteries,  obstruction  of  cerebral,  363 
Arterio-sclerosis,  169 
Arthritis  deformans,  316 

rheumatoid,  316 
Arthropathies,  342 
Ascaris  lumbricoides,  69 
Ascites,  73 
Asthma,  205 
hay,  208 
Ataxia,  locomotor,  376 
Atelectasis  of  lung,  229 
Atheroma,  169 
Athetosis,  334 
Atrophy,  facial,  423 

idiopathic  muscular,  388 
myopathic,  388 
muscular,  causes  of,  341 
of  liver,  acute  yellow,  94 
of  optic  nerve,  346 
progressive  muscular,  385 

509 


510 


INDEX. 


Auscultation,  immediate,  183 

mediate,  183 
Auscultation  of  chest,  183 

of  heart,  141 

B. 

Bacillus,  tubercle,  230 

detection  of,  278 
Baldness,  478 
Bell's  palsy,  403 
Beriberi,  401 
Bile-ducts,  catarrh  of,  82 
Bile  in  the  urine,  104 

tests  for,  104 
Blebs,  causes  of,  440 
Blood,  diseases  of,  119 

examination  of,  119 
Boil,  461 

Bothriocephalus  latus,  68 
Boulimia,  19 
Bradycardia,  144 
Brain,  abscess  of,  369 

anaemia  of,  358 

congestion  of,  357 

softening  of,  365 

tumors  of,  366 
Breath,  fetor  of,  18 
Breathing,  amphoric,  184 

asthmatic,  185 

bronchial,  184 

cavernous,  184 

Cheyne-Stokes,  174 

cogged-wheel,  185 

exaggerated,  184 

jerky,  185 

normal,  184 

puerile,  184 

tidal-wave,  174 

weak,  185 
Bright's  disease,  acute,  107 

chronic,  109,  110 
Bromidrosis,  449 

Bronchial  tubes,  dilatation  of,  203 
Bronchiectasis,  203 
Bronchitis,  197 

acute  catarrhal,  197 

chronic,  200 

fibrinous,  202 
Bronchophony, 185 
Bronchorrhagia,  212 
Bruit,  aneurismal,  141 
Bullse,  causes  of,  440 

c. 

Cachexia,  malarial,  268 


Calculus,  renal,  113 
Calculi,  iDiliary,  83 

pancreatic,  78 
Callositas,  484 
Cancer,  gastric,  47 

hepatic,  91 

pancreatic,  77 
Cancrum  oris,  29 
Canities,  477 
Caput  Medusae,  434 
Carbunculus,  462  • 

Cardiac  dulness,  diminished  area  of, 
141 
increased  area  of,  141 
Catalepsy,  345 
Catarrh,  autumnal,  208 

biliary,  82 

bronchial,  197-200 

gastric,  acute,  37 
chronic,  41 

intestinal,  53 

nasal,  189 

pharyngeal,  33 
Causalgia,  340 
Cephalalgia,  395 
Cerebro-spinal  fever,  261 
Charcot-Leyden  crystals  in  sputum, 

177 
Chest,  auscultation  of,  183 

dulness  of,  on  percussion,  182 

emphysematous,  179 

expansion  of,  181 

inspection  of,  179 

mensuration  of,  187 

palpation  of,  181 

percussion  of,  182 

phthisinoid,  179 

rachitic,  179 
Chest-walls,  oedema  of,  181 
Chevne-Stokes  respiration,  174 
Chicken-pox,  281 
Chloasma,  482 
Chlorides  in  the  urine,  99 
Chlorosis,  132 
Cholsemia,  82 
Cholecvstitis,  acute,  85 
Cholelithiasis,  83 
Cholera,  Asiatic,  298 

infantum,  57 

morbus,  62 
Cholerine,  299 
Cholesteraeraia,  82 
Chorea,  Huntingdon's,  334 

insaniens,  417 

minor,  416 
Choreiform  movements,  causes  of,  333 


INDEX. 


511 


Chyluria,  104 

Circulatory  system,  diseases  of,  137 

Cirrliosis,  hepatic,  87 

pancreatic,  76 
Clavus,  412,  485 
Cold  in  the  head,  188 
Colic,  biliary,  83 

definition  of,  25 

intestinal,  52 

mucous,  54 

pancreatic,  78 

renal,  114 
Coma,  causes  of,  343 
Comedo,  451 

Compensation  in  heart  disease,  153 
Conception,  imperative,  347 
Congestion,  cerebral,  357 

hepatic,  86 

pulmonary,  214 

renal,  105 
Consciousness,  disturbances  of,  343 
Consumption,  pulmonary,  230 
Contraction,  paradoxical,  338 
Convulsions,  331 

epileptiform,  331 

hysteroidal,  332 

local,  333 

salaam,  333 

tetanic,  332 

varieties  of,  331 
Corn,  485 

Cornu  cutaneum,  486 
Corpuscles,    blood,    enumeration     of, 
121 

red,  increase  of,  125 
nucleated,  125 
varieties  of,  125 

white,  decrease  of,  126 
increase  of,  126 
varieties  of,  125 
Corrigan's  pulse,  146 
Coryza,  188 
Cough,  cause  of,  174 

dry,  174 

laryngeal,  174 

moist,  174 

winter,  200 
Cow-pox,  281 
Cramp,  artisans',  420 

writers',  420 
Cretinism,  370 
Crisis,  definition  of,  245 

diseases  terminating  by,  249 
Croup,  false,  194 

membranous,  195 

pseudo-membranous,  195 


Croup,  spasmodic,  194 

true,  195 
Crusts,  cutaneous,  causes  of,  444 
Cyanosis,  causes  of,  147 

congenital,  147 

D. 

Decubitus,  343 

Defecation,  painful,  causes  of,  25 
Degeneration,  reactions  of,  341 
Delusions,  varieties  of,  347 
Delirium,  causes  of,  348 

definition  of,  348 

tremens,  426 
Dengue,  303 
Dermatalgia,  501 
Dermatitis,  469 

exfoliativa,  471 

herpetiformis,  468 
Dermatolysis,  490 
Diabetes  insipidus,  324 

mellitus,  321 
Diacetic  acid,  test  for,  103 
Diaceturia,  cause  of,  103 
Diarrhoea,  52,  53 

varieties  of,  52 
Diathesis,  lithic  acid,  319 

uric  acid,  319 
Digestive  system,  diseases  of,  17 
Diphtheria,  288 

antitoxin  in,  292 
Dipsomania,  426 
Disease,  Addison's,  133 

Basedow's,  133 

bleeder's,  326 

caisson,  388 

Duchenne's,  376 

Friedreich's,  381 

Glenard's,  49 

Graves',  133 

Hodgkin's,  131 

Landry's,  387 

Marie's,  423 

Meniere's,  410 

Morvan's,  382 

Parkinson's,  418 

Thomsen's,  421 
Dizziness,  409 
Dropsy  causes  of,  147 
Dysentery,  59 

amcebic,  59,  60 

catarrhal,  59,  60 

chronic,  60 

diphtheritic,  59,  60 

malignant,  59,  60 


512 


INDEX. 


Dyspepsia,  38 

atonic,  39 

catarrhal,  39 

nervous,  41 
Dysphagia,  causes  of,  19 

E. 

Echinococcus  of  the  liver,  93 

Eclampsia,  332 

Ecstasy,  345 

Ecthyma,  471 

Eczema,  464 

Effusion,  abdominal  (see  Ascites),  73 

pericardial,  150 

pleural,  237,  241,  243 
Elephantiasis,  489 

GrEecorum,.498 
Embolism,  cerebral,  363 
Emesis,  19 
Emphysema,  cutaneous,  causes  of,  434 

pulmonary,  209 

varieties  of,  209 
Empyema  (see  Pleurisy),  239,  243 
Encephalitis,  suppurative,  369 
Endocarditis,  acute,  151 

chronic,  151-153 

malignant,  159 

sclerotic,  lol-153 

ulcerative,  159 

vegetative,  151 
Enteralgia,  52 
Enteritis,  acute,  53 

catarrhal,  53 

chronic,  53 

membranous,  54 
Entero-colitis,  56 
Enteroptosis,  49 
Entrorrhagia,  causes  of,  26 
Epilepsy,  404 
Epistaxis,  causes  of,  172 
Epithelioma,  cutaneous,  500 
Eruptions,  time  of  appearance  of,  247 
Erysipelas,  283 
Erythema,  453 
Exhaustion,  heat,  425 
Exophthalmic  goitre,  133 
Expectoration,  varieties  of,  175 
Eyeball,  tremor  of,  346 
Eyes,  conjugate  deviation  of,  346 

F. 

Face,  atrophy  of,  423 
palsy  of,  403 
spasm  of,  333 


Fastigium,  definition  of,  245 
Favus,  506 
Febricula,  250 
Fecal  discharges,  26 
Festination,  335 
Fever,  245 

gestivo-autumual,  267 

break-bone,  303 

catarrhal,  295 

causes  of,  245 

cerebro-spinal,  261 

degrees  of,  245 

detection  of,  245 

enteric,  251 

ephemeral,  250 

famine,  260 

hay,  208 

intermittent,  266 

lung,  216 

malarial,  266 

pulse-temperature,  ratio  in,  246 

relapsing,  260 

remittent,  267 

rheumatic,  304 

scarlet,  271 

simple  continued,  250 

spirillum,  260 

spotted,  461 

stages  of,  245 

symptoms  of,  245 

terminations  of,  245 

thermic,  424 

treatment  of,  245 

types  of,  245 

typhoid,  251 

typhus,  258 

yellow,  285 
Fevers,  continued,  245 

intermittent,  245 

remittent,  245 
Fibre,  elastic,  in  sputum,  176 
Fibroma,  cutaneous,  491 
Filaria  sanguinis  hominis,  70 
Floating  kidney,  117 
Freckle,  482 
Fremitus,  tactile,  181 

vocal,  181 
Friction-sounds,  pericardial,  141 

pleural,  187 
Friedreich's  disease,  381 
Furunculus,  461 


G. 


Gait,  ataxic,  335 
spastic,  335 


INDEX. 


513 


Gait,  steppage,  335 
Gall-bladder,  inflammation  of,  85 

-ducts,  inflammation  of,  82 

-stones,      b'.i 
Gangrene,  symmetrical,  '.iio,  422 
Gastialgia,  43 
Gastrectasis,  48 
Gastric  cancer,  47 

catarrh,  37,  41 

contents,  acidity  of,  24 
examination  of,  21 

ulcer,  45 
Gastritis,  acute,  37 

chronic,  41 
Gastrodynia,  43 
Gastroptosis,  49 
Glenard's  disease,  49 
Glottis,  oedema  of,  196 

spasm  of,  195 
Glucose,  tests  for,  100 
Glycosuria,  causes  of  100 
Goitre,  exophthalmic,  133 
Gout,  313 

latent,  319 

rheumatic,  316 
Graphospasm,  420 
Green  sickness,  132 

H. 

Hsematemesis,  causes  of,  50 
Hsematoidin  in  sputum,  177 
Hsematoma  of  the  dura  mater,  352 
Hsematuria,  103 
Hsemic  murmurs,  142 
Hajmoglobin,  estimation  of,  119 
Hfemoglobinuria,  causes  of,  104 
Hferaopericardium,  151 
Hemophilia,  326 
Hsemoptysis,  212 

causes  of,  212 
Hsemothorax,  243 
Hair,  atrophy  of,  477 

hypertrophy  of,  488 

trophic  affections  of,  343 
Hallucination,  347 
Hay  fever,  208 
Headache,  395 
Heart,  auscultation  of,  141 

dilatation  of,  162 

fatty  degeneration  of,  164 

fibroid,  160 

hypertrophy  of,  161 

infiltration  "^of,  163 

inspection  of,  137 

neuralgia  of,  165 

33 


Heart,  palpation  of,  140 

palpitation  of,  146 

percussion  of,  140 
Heart-sounds,  accentuation  of,  141 
Heart-sounds,  reduplication  of,  142 

weakness  of,  142 
Heat  exhaustion,  425 
Hemiansesthesia,  338 
Hemiatrophy,  facial,  423 
Hemicrania,  395 
Hemiplegia,  causes  of,  329 
Hemorrhage,  cerebral,  359 

broncho-puhuonary,  212 

from  the  intestines,  26 
kidneys,  103 
lungs,  212 
nose,  172 
stomach,  50 
Hepatitis,  acute  parenchymatous,  94 

catarrhal,  82 

interstitial,  chronic,  67 
Herpes  iris,  458 

simplex,  456 

zoster,  457 
Hiccough,  causes  of,  25 
Hirsuties.  488 
Hives,  455 

Hodgkin's  disease,  131 
Hydatids  of  liver,  93 
Hydremia,  124 
Hydrocephalus,  353 

acute,  349 
Hydronephrosis,  116 
Hydropericardium,  150 
H'ydrophobia,  304 
Hydrothorax,  241 
Hypersemia,  cerebral,  357 

hepatic,  86 

pulmonary,  214 

renal,  105 
Hypersesthesia,  causes  of,  339,  340 
Hyperidrosis,  448 
Hypertrichosis,  488 
Hypertrophy,  cardiac,  161 

pseudo-muscular,  389 
Hysteria,  411 


I. 


Ichthyosis,  487 
Icterus,  80 

neonatorum,  81 
Ileus,  varieties  of,  65 
Illusion,  347 
Impetigo,  473 

contagiosa,  474 


512 


INDEX. 


Dyspepsia,  38 

atonic,  39 

catarrhal,  39 

nervous,  41 
Dysphagia,  causes  of,  19 

E. 

Echinococcus  of  the  liver,  93 

Eclampsia,  332 

Ecstasy,  345 

Ecthyma,  471 

Eczema,  464 

EflFusion,  abdominal  (see  Ascites),  73 

pericardial,  150 

pleural,  237,  241,  243 
Elephantiasis,  489 

Gr8ecorum,.498 
Embolism,  cerebral,  363 
Emesis,  19 
Emphysema,  cutaneous,  causes  of,  434 

pulmonary,  209 

varieties  of,  209 
Empyema  (see  Pleurisy),  239,  243 
Encephalitis,  suppurative,  369 
Endocarditis,  acute,  151 

chronic,  151-153 

malignant,  159 

sclerotic,  151-153 

ulcerative,  159 

vegetative,  151 
Enteralgia,  52 
Enteritis,  acute,  53 

catarrhal,  53 

chronic,  53 

membranous,  54 
Entero-colitis,  56 
Enteroptosis,  49 
Entrorrhagia,  causes  of,  26 
Epilepsy,  404 
Epistaxis,  causes  of,  172 
Epithelioma,  cutaneous,  500 
Eruptions,  time  of  appearance  of,  247 
Erysipelas,  283 
Erythema,  453 
Exhaustion,  heat,  425 
Exophthalmic  goitre,  133 
Expectoration,  varieties  of,  175 
Eyeball,  tremor  of,  346 
Eyes,  conjugate  deviation  of,  346 

F. 

Face,  atrophy  of,  423 
palsy  of,  403 
spasm  of,  333 


Fastigium,  definition  of,  245 
Favus,  506 
Febricula,  250 
Fecal  discharges,  26 
Festination,  335 
Fever,  245 

gestivo-autumual,  267 

break-bone,  303 

catarrhal,  295 

causes  of,  245 

cerebro-spinal,  261 

degrees  of,  245 

detection  of,  245 

enteric,  251 

ephemeral,  250 

famine,  260 

hay,  208 

intermittent,  266 

lung,  216 

malarial,  266 

pulse-temperature,  ratio  in,  246 

relapsing,  260 

remittent,  267 

rheumatic,  304 

scarlet,  271 

simple  continued,  250 

spirillum,  260 

spotted,  461 

stages  of,  245 

symptoms  of,  245 

terminations  of,  245 

thermic,  424 

treatment  of,  245 

types  of,  245 

typhoid,  251 

typhus,  258 

yellow,  285 
Fevers,  continued,  245 

intermittent,  245 

remittent,  245 
Fibre,  elastic,  in  sputum,  176 
Fibroma,  cutaneous,  491 
Filaria  sanguinis  hominis,  70 
Floating  kidney,  117 
Freckle,  482 
Fremitus,  tactile,  181 

vocal,  181 
Friction-sounds,  pericardial,  141 

pleural,  187 
Friedreich's  disease,  381 
Furunculus,  461 


G. 


Gait,  ataxic,  335 
spastic,  335 


INDEX. 


513 


Gait,  steppage,  335 

Gall-bladder,  inflammation  of,  85 

-ducts,  ijiflammatiou  of,  82 

-stones,      S3 
Gangrene,  symmetrical,  343,  422 
Gastralgia,  43 
Gastrectasis,  48 
Gastric  cancer,  47 

catarrh,  37,  41 

contents,  acidity  of,  24 
examination  of,  21 

ulcer,  45 
Gastritis,  acute,  37 

chronic,  41 
Gastrodynia,  43 
Gastroptosis,  49 
Glenard's  disease,  49 
Glottis,  oedema  of,  196 

spasm  of,  195 
Glucose,  tests  for,  100 
Glycosuria,  causes  of  100 
Goitre,  exophthalmic,  133 
Gout,  313 

latent,  319 

rheumatic,  316 
Graphospasm,  420 
Green  sickness,  132 

H. 

Hsematemesis,  causes  of,  50 
Hsematoidin  in  sputum,  177 
Hsematoma  of  the  dura  mater,  352 
Hsematuria,  103 
Hsemic  murmurs,  142 
Haemoglobin,  estimation  of,  119 
Hsemoglobinuria,  causes  of,  104 
Hsemopericardium,  151 
Hemophilia,  326 
Haemoptysis,  212 

causes  of,  212 
Hgemothorax,  243 
Hair,  atrophy  of,  477 

hypertrophy  of,  488 

trophic  affections  of,  343 
Hallucination,  347 
Hay  fever,  208 
Headache,  395 
Heart,  auscultation  of,  141 

dilatation  of,  162 

fatty  degeneration  of,  164 

fibroid,  160 

hypertrophy  of,  161 

infiltration  of,  163 

inspection  of,  137 

neuralgia  of,  165 

33 


Heart,  palpation  of,  140 

palpitation  of,  146 

percussion  of,  140 
Heart-sounds,  accentuation  of,  141 
Heart-sounds,  reduplication  of,  142 

weakness  of,  142 
Heat  exhaustion,  425 
Hemiansesthesia,  338 
Hemiatrophy,  facial,  423 
Hemicrania,  395 
Hemiplegia,  causes  of,  329 
Hemorrhage,  cerebral,  359 

broncho-pulmonary,  212 

from  the  intestines,  26 
kidneys,  103 
lungs,  212 
nose,  172 
stomach,  50 
Hepatitis,  acute  parenchymatous,  94 

catarrhal,  b2 

interstitial,  chronic,  67 
Herpes  iris,  458 

simples,  456 

zoster,  457 
Hiccough,  causes  of,  25 
Hirsuties.  488 
Hives,  455 

Hodgkin's  disease,  131 
Hydatids  of  liver,  93 
Hydrpemia,  124 
Hydrocephalus,  353 

acute,  349 
Hydronephrosis,  116 
Hydropericardium,  150 
Hydroi)hobia,  304 
Hydrothorax,  241 
Hyperfemia,  cerebral,  357 

hepatic,  86 

pulmonary,  214 

renal,  105 
Hypersesthesia,  causes  of,  339,  340 
Hyperidrosis,  448 
Hypertrichosis,  488 
Hypertrophy,  cardiac,  161 

pseudo-muscular,  389 
Hysteria,  411 

I. 

Ichthyosis,  487 
Icterus,  80 

neonatorum,  81 
Ileus,  varieties  of,  65 
Illusion,  347 
Impetigo,  473 

contagiosa,  474 


516 


INDEX. 


Paraplegia,  causes  of,  330 

primary  spastic,  379 
Piirasites,  blood,  127 

intestinal,  tib 
Paretic  dementia,  355 
Parosmia,  171 
Parotitis  (see  Mumps),  297 
Pectoriloquy,  lt>5 
Pediculosis,  507 

capitis,  507 

corporis,  507 

pubis,  503 
Pfliosis  rheumatica,  437  ' 
Pemphigus,  472 
Percussion,  immediate,  182 

mediate,  182 

of  the  heart,  140 

of  the  lungs,  182 
Pericarditis,  14« 
Pericardium,  adherent,  149 

air  in,  151 

blood  in,  151- ' 

dropsy  of,  150 
Peritonitis,  72 
Perityphlitis,  63 
Pernicious  anemia,  128 
Pertussis,  293 
Petechise,  causes  of,  436 
Pharyngitis,  33 
Phosphates  in  the  urine,  98 
Phtheiriasis.  507 
Phthisis,  230 

acute,  233 

chronic  ulcerative,  230 

fibroid,  233 
Pica,  19 

Pitvriasis  versicolor,  505 
Plethora,  124 
Pleurisy,  acute,  237 

diaphragmatic,  239 

fibrinous,  239 

hemorrhagic.  239 

purulent,  243 

tuberculous,  239. 
Pleurodynia,  311 
Plunibism,  429 
Pneumonia,  alcoholic.  216 

broncho-,  221 

catarrhal,  221 

chronic  interstitial,  225 

croupous,  216 

hypostatic,  214 

lobar,  216 

lobular,    221 

senile,  218 

typhoid,  218 


Pneumopericardium,  151 
Pneumothorax,  241 

hydro-,  241 

pyo-,  241 
Poikilocytosis,  125 
Poisoning,  arsenical,  chronic,  431 

lead,  chronic,  429 

mercurial,  chronic,  430 

opium,  428 
Poliomyelitis,  acute  anterior,  383 

chronic,  385 
Polycythsemia,  125 
Polyuria,  causes  of,  95 
Pompholyx,  481 
Prickly  heat,  475 

Progressive  muscular  atrophy,  385 
Prurigo,  468 
Pruritus,  502 
Pseudo-leuksemia,  115 
Pseudo-muscular  hypertrophy,  389 
Psoriasis,  462 
Ptyalism,  29 

Pulmonary  valve,  affections  of,  156 
Pulsation,  abnormal  centres  of,  139 
Pulse,  bigeminal,  144 

Corrigan's,  146 

dicrotic,  145 

high-tension,  145 

increased  frequency  of,  143 

intermittent,  144 

irregular,  144  • 

jugular,  140 

low-tension,  146 

trigeminal,  144 

venous,  146 

water-hammer,  146 
Pulsus  paradoxus,  145 
Pupil,  Argyll-Robertson,  346 
Purpura  hsemorrhagica,  327 
Purpuric  rashes,  causes  of,  436 
Pus  in  the  expectoration,  175 

in  the  stools,  26 

in  the  urine,  104 

in  the  vomit,  20 
Pustules,  causes  of,  440 
Pyelitis,  115 
Pyelonephritis,  115 
Pylorus,  obstruction  of,  48 
Pyonephrosis,  115 
Pvothorax,  243 
Pyrexia,  245 
Pyuria,  causes  of,  104 


Q. 


Quinsy,  30 


INDEX. 


51" 


R. 

Rabies,  304 

Rachitis,  318 

Rales,  186 

Rashes,  time  of  appearance  of,  247 

Ravnaud'.s  disease,  422 

Reaction,  the  Widal,  253 

Reflexes,  deep,  336 

causes  which  decrease,  336 
increase,  336 

superficial,  337 
Relapsing  fever,  260 
Remittent  fever,  267 
Eenal  calculus,  113 

colic,  114 

congestion,  105 

tuberculosis,  118 
Resonance,   pulmonarv,    diminished, 
182 
increased,  182 

outlines  of,  182 

vocal,  diminution  of,  185 
increase  of,  185 
Respiration,  Cheyne-Stokes,  174 

disturbance  of,  173 

normal,  173 
Respiratory    murmur,     modifications 

of,  184 
Retro-pharyngeal  abscess,  34 
Rheumatism,  acute  articular,  306 

chronic,  310 

inflammatory,  306 

muscular,  311 
Rheumatoid  arthritis,  316 
Rhinitis,  188 
Rickets,  318 
Ringworm,  503 
Romberg's  sign,  377 
Rose  cold,  208 
Roseola,  epidemic,  276 
Rotheln,  276 
Rubella.  276 
Rubeola,  274 
Rumination,  25 

s. 

Salaam  convulsions,  333 

Salivation  {see  Mercurial  stomntiiis),  29 

Saltatory  spasm,  333 

Sarcinse  ventriculi,  48 

Scabies,  506 

Scales,     cutaneous,     diseases    which 

cause,  445 
Scarlatina,  271 


Scarlet  fever,  271 
Sciatica,  402 
Sclerema,  488 
Scleriasis,  488 
Scleroderma,  488 
Sclerosis,  arterio-,  169 

amyotrophic,  380 

disseminated,  380 

lateral,  379 

multiple,  380 

posterior.  376 

spinal,  376 
Scorbutus,  325 
Scurvy,  325 
Seborrhcea,  450 

Sensation,  disturbances  of,  338 
Sense,  muscular,  340 

of  pressure,  340 

of  space,  339 
Senses,  special,  disturbances  of,  346 
Skin,  diseases  of,  432 

discolorations  of,  432 

glossy,  340,  434 

hardness  of,  433 

pallor  of,  4.32 
Smallpox,  277 

Smell,  sense  of,  disturbances  of,  171 
Softening,  cerebral,  365 
Somnambulism,  345 
Sound,  cracked-pot,  182 
Sounds,  adventitious  pulmonary,  187 
Spasm,  333 

facial,  333 

laryngeal,  195 

oesophageal,  36 

saltatory,  333 
Spinal  cord,  sclerosis  of,  376 
Sputum,  Charcot-Levden,  crvstals  in, 
177 

elastic  fibre  in,  176 

fatty  acids  in,  177 

hffimatoidin  in,  177 

microscopy  of,  176 

mucin  in,  176 

muco-purulent,  176 

prune-juice,  176 

rusty,  176 

spirals,  Curschmann's,  205 

tubercle  bacilli  in,  178 
Steatoma,  4.53 
Steatorrhcea,  450 
Stenocardia,  165 
Stomach,  absorptive  power  of,  24 

cancer  of,  47 

dilatation,  48 

inflammation  of,  .37,  41 


518 


INDEX. 


Stoinacli,  motor  pov.'er  of,  24 

neuralgia,  43 

ptosis  of,  49 

ulcer  of,  45 
Stomatitis,  27 

Stools,  changes  in,  in  disease,  26 
"Strawberry  tongue,"  18 
Stricture,  intestinal,  67 

cesopbageal,  35 

pyloric,  48 
St.  Vitus'  dance,  416 
Succussion -splash,  187 
Sudamen,  449 
Sugar  in  the  uriue,  100 

tests  for,  100 
Sunstroke,  424 

Sweat-glauds,  diseases  of,  449 
Sycosis,  simple,  480 

tinea,  504 
Symptom,  dissociation,  382 
Syphilis  cutanea,  496 
Syringo-myelia,  382 

T. 

Tabes  dorsalis,  376 

Tachycardia,  125 

Taenia  mediocanellata,  68 

saginata,  68 

solium,  68 
Tape-worm,  varieties  of,  68 
Teeth,  Hutchinson's,  17 
Temperature,    subnormal,    causes    of, 

249 
Tenderness,  abdominal,  25 
Tetanus,  302 
Tetany,  420 

Thermo-ausesthesia,  339 
Thomsen's  disease,  421 
Thrombosis,  cerebral,  363 
Thrush,  28 
Tic  douloureux,  391 
Tinea  cii-cinata,  504 

favosa,  506 

sycosis,  504 

tonsurans,  503 

versicolor,  505 
Tinkling,  metallic,  187 
Tinnitus  aurium,  causes  of,  346 
Titubation,  336 
Tongue,  condition  of,  in  disease,  17 

fur  on,  17 

scars  on,  18 

"strawberry,"  18 

tremor  of,  18 
Tonsillitis,  30 


Tonsils,  hypertrophy  of,  321 
Tormina,  52 
Trance,  344 

Tremors,  causes  of,  335 
Trichina  spiralis,  70 
Trichinosis,  71 
Tricocephalus  dispar,  70 
Tricuspid  valve,  diseases  of,  156 
Tubercle  bacillus,  detection  of,  178 
Tubercles,  cutaneous,  causes  of,  425 
Tuberculosis,  acute  general,  287 

meningeal,  349 

pulmonary,  230 

renal,  118 
Tumors,  cerebral,  366 
Typhlitis,  63 
Typhoid  fever,  251 
Typhus  fever,  258 
Tyrosiu  la  the  urine,  97 

u. 

Ulcer,  gastric,  45 

perforating,  of  the  foot,  343 
Ulcers,  cutaneous,  causes  of,  446 
Ursemia,  106 
Urates,  increase  of,  97 
Urea,  diminution  of,  96 

increase  of,  96 

test  for,  96 
Uric  acid,  test  for,  97 
Urine,  albumin  in,  102 

bile  in,  104 

blood  in,  103 

chlorides  in,  99 

chyle  in,  104 

diminution  of,  95 

increase  of,  95 

indican  in,  104 

leucin  in,  97 

oxalates  iu,  99 

phosphates  in,  98 

pus  in,  104 

sugar  in, 100 

tyrosiu  in,  97 

urea  in,  96 

uric  acid  in,  96 
Urobilinuria,  100 
Urticaria,  455 

T. 

Vaccinia,  281 

Vagabondismus,  433 

Valvular  affections  of  the  heart,  153 

Varicella,  281 


INDEX. 


519 


Variola,  277 
Varioloid,  279 
\'eri'uca,  486 
Vertigo,  409 

aural,  410 

labyrinthine,  410 
Vesicles,  cutaneous,  causes  of,  438 
Vitiligo,  476 
Vitiligoidea,  492 
Vocal  cords,  paralysis  of,  173 
Voice,  loss  of,  172 
Vomit,  varieties  of,  20 
Vomiting,  causes  of,  19 

TV. 

Wart,  486 

Wen,  453 

Wheals,  causes  of,  444 

Whooping-cough,  293 


Widal  reaction,  253 
Worms,  intestinal,  6 
Writers'  cramp,  420 
Wry-neck,  311 


Xanthelasma,  492 
Xanthoma,  492 


Y. 

Yellow  atrophy  of  liver,  acute,  94 
Yellow  fever,  285 


Z. 

Zona,  457 

Zoster,  herpes,  457 


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Anomalies  and  Curiosities  of  Medicine.  By  GEORGE  M.  GoULD,  M.  D., 
and  Walter  L.  Pyle,  M.  D.  An  encyclopedic  collection  of  rare  and  ex- 
traordinary cases  and  of  the  most  striking  instances  of  abnormality  in  all 
branches  of  Medicine  and  Surgery,  derived  from  an  exhaustive  research  of 
medical  literature  from  its  origin  to  the  present  day,  abstracted,  classified, 
annotated,  and  indexed.  Handsome  octavo  volume  of  968  pages;  295  en- 
gravings and  12  full-page  plates.  Popular  Edition.  Cloth,  ;^3.oo  net ;  Sheeo 
or  Half  Morocco,  ^4.00  net. 

GRADLE  ON  THE  NOSE,  THROAT,  AND  EAR. 

Diseases  of  the  Nose,  Throat,  and  Ear.  By  Henry  Gradle,  M.  D.,  Pro- 
fessor of  Ophthalmology  and  Otology,  Northwestern  University  Medical 
School,  Chicago.  Octavo,  547  pages,  illustrated,  including  2  full-page 
colored  plates.     Cloth,  fo.50  net. 


8  MEDICAL  PUBLICATIONS 


QRAFSTROM'S   MECHANO=THERAPY. 

A  Text-Book  of  Mecliano-Therapy  (Massage  and  Medical  Gymnastics). 
By  Axel  V.  Grafstrom,  B.  Sc.  M.D.,  late  House  Physician,  City  Hos- 
pital, Blackwell's  Island,  N.Y.  i2mo,  139  pages,  illustrated.  Cloth, ^i. 00  net. 

GRANT'S    SURGICAL    DISEASES  OF    THE    FACE,   MOUTH, 
AND  JAWS.     For  Dental  Students. 

A  Text-Book  of  Surgical  Pathology  and  Surgical  Diseases  of  the  Face, 
Mouth,  and  Jaws.  For  Dental  Students.  By  H.  HORACE  GRANT,  A.  M., 
M.D.,  Professor  of  Surgical  Pathology  and  Oral  Surgery,  Louisville  Col- 
lege of  Dentistry;  Professor  of  Surgery  and  Clinical  Surgery,  Hospital 
College  of  Medicine,  Louisville,  Ky.  Octavo  volume  of  215  pages,  with 
60  illustrations.     Cloth,  $0.00  net. 

GRIFFITH  ON  THE  BABY.    Second  Edition,  Revised. 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.  D.,  Clinical  Pro- 
fessor of  Diseases  of  Children,  University  of  Pennsylvania  ;  Physician  to  the 
Children's  Hospital,  Philadelphia,  etc.  i2mo,  404  pages,  67  illustrations 
and  5  plates.     Cloth,  I1.50  net. 

GRIFFITH'S  WEIGHT  CHART. 

Infant's  Weight  Chart.  Designed  by  J.  P.  Crozer  GRIFFITH,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania.  25 
charts  in  each  pad.     Per  pad,  50  cts.  net. 

HAYNES'   ANATOMY. 

A  Manual  of  .Anatomy.  By  IRVING  S.  Ha^'NES,  M.  D.,  Professor  of  Prac- 
tical Anatomy  in  Cornell  University  Medical  College.  680  pages  ;  42  dia- 
grams and  134  full-page  half-tone  illustrations  from  original  photographs  of 
the  author's  dissections.     Cloth,  $2.50  net. 

HEISLER'S  EMBRYOLOGY.     Second  Edition,  Revised. 

A  Text-Book  of  Embryolog^^  By  JOHN  C.  Heisler,  M.  D.,  Professor  of 
Anatomy,  Medico-Chirurgical  College,  Philadelphia.  Octavo  volume  of  405 
pages,  handsomely  illustrated.     Cloth,  $2.50  net. 

HIRST'S  OBSTETRICS.    Third  Edition,  Revised  and  Enlarged. 

A  Text-Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.D.,  Professor 
of  Obstetrics,  University  of  Pennsylvania.  Handsome  octavo  volume  of 
873  pages,  704  illustrations,  36  of  them  in  colors.  Cloth,  ^5.00  net;  Sheep 
or  Half  Morocco,  $6.00  net. 

HYDE  &  MONTGOMERY  ON  SYPHILIS  AND  THE  VENEREAL 
DISEASES.    2d  Edition,  Revised  and  Greatly  Enlarged. 

Syphilis  and  the  Venereal  Diseases.  By  James  Nevins  Hyde,  M.  D.,  Pro- 
fessor of  Skin,  Genito-Urinary,  and  Venereal  Diseases,  and  FRANK  H. 
Montgomery,  M.D.,  .Associate  Professor  of  Skin,  Genito-Urinary,  and 
Venereal  Diseases  in  Rush  Medical  College,  Chicago,  111.  Octavo,  594 
pages,  profusely  illustrated.     Cloth,  $4.00  net. 


OF  W.  B.   SA  UNDERS  &^  CO. 


INTERNATIONAL  TEXT=BOOK  OF  SURGERY.    Two  Volumes. 
2d  Ed.,  Thoroughly  Revised  and  Greatly  Enlarged. 

By  American  and  British  Authors.  Edited  by  J.  COLLINS  Warren,  M.  D., 
LL.  D.,  F.  R.C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Medical  School, 
Boston;  and  A.  Pearce  Gould,  M.  S.,  F.  R.  C.  S.,  Lecturer  on  Practical 
Surgery  and  Teacher  of  Operative  Surgery,  Middlesex  Hospital  Medical 
School,  London,  Eng.  Vol.  L  General  Su7-gery. — Handsome  octavo,  947 
pages,  with  458  beautiful  illustrations  and  9  lithographic  plates.  Vol.  IL 
Special  or  Regional  Surgery. — Handsome  octavo,  1072  pages,  with  471 
beautiful  illustrations  and  8  lithographic  plates.  Prices  per  volume : 
Cloth,  ^5.00  net;  Sheep  or  Half  Morocco,  ^6.00  net. 

"  It  is  the  most  valuable  work  on  the  subject  that  has  appeared  in  some  years.  The 
clinician  and  the  patholog^ist  have  joined  hands  in  its  production,  and  the  result  must  be  a 
satisfaction  to  the  editors  as  it  is  a  gratification  to  the  conscientious  reader." — Annals  of 
Surgery. 

"  This  is  a  work  which  comes  to  us  on  its  own  intrinsic  merits.  Of  the  latter  it  has 
very  many.  The  arrangement  of  subjects  is  excellent,  and  their  treatment  by  the  different 
authors  is  equally  so.  What  is  especially  to  be  recommended  is  the  painstaking  endeavor 
of  each  writer  to  make  his  subject  clear  and  to  the  point.  To  this  end  particularly  is  the 
technique  of  operations  lucidly  described  in  all  necessary  detail.  And  withal  the  work  is  up 
to  date  in  a  very  remarkable  degree,  many  of  the  latest  operations  in  the  different  regional 
parts  of  the  body  being  given  in  full  details.  There  is  not  a  chapter  in  the  work  from  which 
the  reader  may  not  learn  something  new." — Rtedical  Record,  New  York. 

JACKSON'S  DISEASES  OF  THE  EYE. 

A  Manual  of  Diseases  of  the  Eye.  By  Edward  Jackson,  A.M.,  M.  D., 
Emeritus  Professor  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic  and  Col- 
lege for  Graduates  in  Medicine.  i2mo,  volume  of  535  pages,  with  178  illus- 
trations, mostly  from  drawings  by  the  author.     Cloth,  ^2.50  net. 

JELLIFFE  AND  DIEKMAN'S  CHEMISTRY. 

A  Text-Book  of  Chemistry.  By  SMITH  Ely  Jelliffe,  M.  D.,  Ph.  D., 
Professor  of  Pharmacology,  College  of  Pharmacy,  New  York  ;  and  GEORGE 
C.  DiEKMAN,  Ph.G.,  M.  D.,  Professor  of  Theoretical  and  Applied  Phar- 
macy, College    of  Pharmacy,  New  York.     Octavo,  550  pages,   illustrated. 

Ready  Shortly. 

KEATING'S  LIFE  INSURANCE. 

How  to  Examine  for  Life  Insurance.  By  John  M.  Keating,  M.  D.,  Fellow 
of  the  College  of  Physicians  of  Philadelphia  ;  Ex-President  of  the  Association 
of  Life  Insurance  Medical  Directors.  Royal  octavo,  211  pages.  With 
numerous  illustrations.     Cloth,  ^2.00  net. 

KEEN  ON  THE  SURGERY  OF  TYPHOID  FEVER. 

The  Surgical  Complications  and  Sequels  of  Typhoid  Fever.  By  Wm.  W. 
Keen,  M.  D.,  LL.D.,  F,  R.  C.  S.  (Hon.),  Professor  of  the  Principles  of  Sur- 
gery and  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadelphia,  etc. 
Octavo  volume  of  386  pages,  illustrated.     Cloth,  ^3.00  net. 

KEEN'S  OPERATION  BLANK.    Second  Edition,  Revised  Form. 

An  Operation  Blank,  with  Lists  of  Instruments,  etc.  Required  in  Various 
Operations.  Prepared  by  W.  W.  Keen,  M.  D.,  LL.D.,  F.  R.  C.  S.  (Hon.), 
Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery,  Jefferson 
Medical  College,  Philadelphia.     Price  per  pad,  of  50  blanks,  50  cts.  net. 

KYLE  ON  THE  NOSE  AND  THROAT.    Second  Edition. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D.,  Clinical 
Professor  of  Laryngology  and  Rhinology,  Jefferson  Medical  College,  Phila- 
delphia. Octavo,  646  pages  ;  over  150  illustrations  and  6  lithographic  plates. 
Cloth,  ^4.00  net;  Sheep  or  Half  Morocco,  ^5.00  net. 


MEDICAL  PUBLICATIONS 


LAINE'S  TEMPERATURE  CHART. 

Temperature  Chart.  Prepared  by  D.  T.  Laine,  M.  D.  Size  8  x  13^^ 
inches.  A  conveniently  arranged  Chart  for  recording  Temperature,  with 
columns  for  daily  amounts  of  Urinary  and  Fecal  Excretions,  Food,  Re- 
marks, etc.  On  the  back  of  each  chart  is  given  the  Brand  treatment  of 
Typhoid  Fever.     Price,  per  pad  of  25  charts,  50  cts.  net. 

LEVY,  KLEMPERER,  AND   ESHNER'S  CLINICAL  BACTERI= 
OLOQY. 

The  Elements  of  Clinical  Bacteriology.  By  Dr.  Ernst  Levy,  Professor 
in  the  University  of  Strasburg,  and  Dr.  Felix  Klemperer,  Privatdocent 
in  the  University  of  Strasburg.  Translated  and  edited  by  AUGUSTUS  A. 
ESHNER,  M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinii;. 
Octavo,  440  pages,  fully  illustrated.     Cloth,  $2.50  net. 

LOCKWOOD'S    PRACTICE    OF    MEDICINE.     Second   Edition, 
Revised  and  Enlarged. 

A  Manual  of  the  Practice  of  Medicine.  By  GEORGE  ROE  LOCKWOOD, 
M.  D.,  Attending  Physician  to  Bellevue  Hospital,  New  York.  Octavo,  84" 
pages,  fully  illustra+ed,  including  22  colored  plates.     Cloth,  ^4.00  net. 

LONG'S  SYLLABUS  OF  QYNECOLOQY. 

A  Syllabus  of  Gynecology,  arranged  in  Conformity  with  "An  American 
Text-Book  of  Gynecology."  By  J.  W.  Long,  M.  D.,  Professor  of  Dis- 
eases of  Women  and  Children,  Medical  College  of  Virginia,  etc.  Clotli 
interleaved,  $1.00  net. 

MACDONALD'S  SURGICAL  DIAGNOSIS   AND  TREATMENT. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  Macdonald,  M.  D.  Edin., 
F.  R.  C.  S.  Edin.,  Professor  of  Practice  of  Surgery  and  Clinical  Surgery, 
Hamline  University.  Handsome  octavo,  800  pages,  fully  illustrated.  Cloth, 
^5.00  net;  Sheep  or  Half  Morocco,  ^6.00  net. 

MALLORY  AND  WRIGHT'S  PATHOLOGICAL  TECHNIQUE. 
Second  Edition,  Revised  and  Enlarged. 

Pathological  Technique.  A  Practical  Manual  for  Laboratory  Work  in 
Pathology,  Bacteriology,  and  Morbid  Anatomv,  with  chapters  on  Post- 
Mortem  Technique  and  the  Performance  of  Autopsies.  By  FRANK  B. 
Mallory,  a.  M.,  M.  D.,  Assistant  Professor  of  Pathology,  Harvard  Uni- 
versity Medical  School,  Boston;  and  JAMES  H.  Wright,  A.  M.,  M.D., 
Instructor  in  Pathology,  Harvard  University  Medical  School,  Boston. 
Octavo,  432  pages,  fully  illustrated.     Cloth,  $3.00  net. 

McCLELLAN'S  ANATOMY  IN  ITS  RELATION  TO  ART. 

Anatomy  in  its  Relation  to  Art.  An  Exposition  of  the  Bones  and  Muscles 
of  the  Human  Body,  with  Reference  to  their  Influence  upon  its.Actions, 
and  External  Form.  By  GEORGE  McClellan,  M.  D.,  Professor  of  Anat- 
omy, Pennsylvania  Academy  of  Fine  Arts.  Handsome  quarto,  9  by  iiVi 
inches.  Illustrated  with  338  original  drawings  and  photographs,  260  pages 
of  text.     Dark  Blue  Vellum,  $10.00  net ;   Half  Russia,  $12.00  net. 

McCLELLAN'S  REGIONAL  ANATOMY.     Fourth   Edition,  Re= 
vised. 

Regional  Anatomy  in  its  Relations  to  Medicine  and  Surgerv.  By  GEORGE 
McClellan,  M.  D.,  Professor  of  Anatomy  at  the  Pennsylvania  Academy 
of  Fine  Arts.  In  two  handsome  quarto  volumes,  884  pages  of  text,  and 
97  full-page  chromo-lithographic  ])lates,  reproducing  the  author's  original 
dissections.      Price:   Cloth,  $12,00  net;    Half  Russia,  $15.00  net. 


OF  W.  B.  SAUNDERS  &=  CO. 


McFARLAND'S    PATHOGENIC    BACTERIA.      Third    Edition, 
increased  in  size  by  over  lOO  Pages. 

Text  Book   upon    the    Pathogenic    Bacteria.      By    JOSEPH    McFarland, 
M  D     ProfesLr  of  Pathology  and  Bacteriology,  Med.co-Ctourg.calC^ 
lege,  Phila.,  etc.     Octavo,  621  pages,  finely  illustrated.     Cloth,  ^s-^S  net. 

MEIGS  ON  FEEDING  IN  INFANCY. 

Feeding  in  Early  Infancy.  By  ARTHUR  V.  MEIGS.  M.  D.  Bound  in  limp 
cloth,  flush  edges,  25  cts.  net. 

MOORE'S  ORTHOPEDIC  SURGERY. 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M  D.,  Professor 
of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery.  University  of 
MinnesS  College  of  Medicine  and  Surgery.  Octavo  volume  of  356  pages, 
handsomely  illustrated.     Cloth,  $2.50  net. 

MORTEN'S  NURSES'  DICTIONARY. 

Nurses'  Dictionary  of  Medical  Terms  and  Nursing  Treatment  Contaming 
Definition  of  the  Principal  Medical  and  Nursing  Terms  and  Abbreviations  ; 
S  the  Instruments,  Dmgs,  Diseases,  Accidents,  Treatments  Operations 
Foods,  Appliances,  etc.  encountered  in  the  ward  or  in  the  sick-room^  By 
HONNOR  MORTEN,  author  of  "  How  to  Become  a  Nurse,  etc.  i6mo,  140 
pages.     Cloth,  |i. 00  net. 

NANCREDE'S  ANATOMY  AND  DISSECTION.    Fourth  Edition. 

Essentials  of  Anatomy  and  Manual  of  Practical  dissection  By  Charles 
B  NaNCREDE,  M.  D.,  LL.D.,  Professor  of  Surgery  and  of  Chmcal  Surgery 
University  of  Michigan,  Ann  Arbor.  Post-octavo  500  pages  with  fuH-page 
lithographic  plates  in  colors  and  neariy  200  illustrations.  Extra  Cloth  (or 
Oilcloth  for  dissection-room),  ;^2.oo  net. 

NANCREDE'S  PRINCIPLES  OF  SURGERY. 

Lectures  on  the  Principles  of  Surgery.  By  CHARLES  B.  NANCREDE  M.  D., 
tuD  Professor  of  Su^rgery  and  of  Clinical  Surgery,  University  of  Michigan, 
Ann  Arbor.     Octavo,  398  pages,  illustrated.     Cloth,  ^2.50  net. 

NORRIS'S    SYLLABUS    OF    OBSTETRICS.     Third    Edition, 
Revised. 

Syllabus  of  Obstetrical  Lectures  in  the  Medical  Department,  University  of 
Pennsylvania.  Bv  RICHARD  C.  NoRRlS,  A.  MM.  D.,  Instructor  m  Obstet- 
rics and  Lecturer  on  Clinical  and  Operative  Obstetrics,  University  of  Penn- 
sylvania.    Crown  octavo,  222  pages.     Cloth,  interieaved,  ^2.00  net. 

OGDEN  ON  THE  URINE.  . 

Clinical  Examination  of  the  Urine  and  Urinary  Diagnosis.  A  Chmcal  Guide 
for  the  Use  of  Practitioners  and  Students  of  Medicine  and  Surgeiy.HJ  J- 
BERGEN  Ogden,  M.  D.,  lately  Instructor  m  Chemistry,  Harvard  Univer- 
sity Medical  School.  Handsome  octavo,  416  pages,  with  54  illustrations 
and  a  number  of  colored  plates.      Cloth,  fe.oo  net. 

PENROSE'S  DISEASES  OF  WOMEN.    Fourth  Edition,  Revised. 

A  Text-Book  of  Diseases  of  Women.  By  Charles  B.  Penrose,  M.  D.. 
Ph  D  formerly  Professor  of  Gynecology  in  the  University  of  Pennsylvania. 
Octavo'  volume  of  S39  pages,  with  221  illustrations.     Cloth,  $3.75  net. 


MEDICAL  PUBLICATIONS 


PYE'S  BANDAGING. 

Elementary  Bandaging  and  Surgical  Dressing.  With  Directions  concerning 
the  Immediate  Treatment  of  Cases  of  Emergency.  By  WALTER  PYE, 
F.  R.  C.  S.,  late  Surgeon  to  St.  Mary's  Hospital,  London.  Small  i2mo, 
over  80  illustrations.     Cloth,  fle.xible  covers,  75  cts.  net. 

PYLE'S  PERSONAL  HYGIENE. 

A  Manual  of  Personal  Hygiene.  Proper  Living  upon  a  Physiologic  Basis. 
Edited  by  Walter  L.  Pyle,  M.  D.,  Assistant  Surgeon  to  the  Wills  Eye 
Hospital,  Philadelphia.  Octavo  volume  of  344  pages,  fully  illustrated. 
Cloth,  ^1.50  net. 

RAYMOND'S    PHYSIOLOGY.      Second   Edition,   Entirely    Re= 
written  and  Greatly  Enlarged. 

A  Text-Book  of  Physiology.  By  JOSEPH  H.  RAYMOND,  A.M.,  M.  D., 
Professor  of  Physiology  and  Hygiene  in  the  Long  Island  College  Hospital, 
and  Director  of  Physiology  in  Hoagland  Laboratory,  New  York.  Octavo, 
668  pages,  443  illustrations.     Cloth,  $3.50  net. 

ROBSON  AND  MOYNIHAN'S  DISEASES  OF  THE  PANCREAS. 

Diseases  of  the  Pancreas.  By  A.  W.  Mayo  Robson,  F.  R.  C.  S.,  Leeds, 
Senior  Surgeon  to  Leeds  General  Infirmary  ;  Emeritus  Professor  of  Surgery, 
Yorkshire  College  of  Victoria  University  ;' and  B.  G.  A.  MOYNIHAN,  M.  B., 
F.  R.  C.  S.,  Assistant  Surgeon  Leeds  General  Infirmary;  Demonstrator  of 
Anatomy,  Yorkshire  College.  Handsome  octavo  of  300  pages,  illustrated. 
Cloth,     go. 00  net. 

SALINGER  AND  KALTEYER'S  MODERN  MEDICINE. 

Modern  Medicine.  By  JiLiLS  L.  Salinger,  ;M.  D.,  Professor  of  Clin- 
ical Medicine,  Jefferson  Medical  College  ;  and  F.  J.  K,\LTEYER,  M.  D., 
Assistant  in  Clinical  Medicine,  Jefferson  Medical  College.  Handsome- 
octavo,  801  pages,  illustrated.     Cloth,  $4.00  net. 

SAUNDBY'S  RENAL  AND  URINARY  DISEASES. 

Lectures  on  Renal  and  Urinary  Diseases.  By  ROBERT  S.\UNDBY,  M.  D. 
Edin.,  Fellow  of  the  Royal  College  of  Physicians,  London,  and  of  the  Royal 
Medico-Chirurgical  Society  ;  Professor  of  Medicine  in  Mason  College,  Bir- 
mingham, etc.  Octavo,  434  pages,  with  numerous  illustrations  and  4  colored 
plates.     Cloth,  $2.50  net. 

SAUNDERS'  MEDICAL  HAND-ATLASES.    See  pages  17,  18, 
and  19. 

SAUNDERS'   POCKET   MEDICAL   FORMULARY.     Sixth   Edi= 
tion,  Revised. 

By  William  M.  Powell,  M.  D.,  author  of  "Essentials  of  Diseases  of 
Children  "  ;  Member  of  Philadelphia  Pathological  Society.  Containing  1844 
formulae  from  the  best-known  authorities.  With  an  Appendix  containing 
Posological  Table,  Formulae  and  Doses  for  Hypodermic  Medication, 
Poisons  and  their  Antidotes,  Diameters  of  the  Female  Pelvis  and  Fetal 
Head,  Obstetrical  Table,  Diet  Lists,  Materials  and  Drugs  used  in  Antiseptic 
Surgery,  Treatment  of  Asphvxia  from  Drowning,  Surgical  Remembrancer, 
Tables  of  Incompatibles,  Eruptive  Fevers,  etc.,  etc.  Flexible  morocco, 
with  side  index,  wallet,  and  flap.     32. 00  net. 


OF  W.  B.  SAUNDERS  &-  CO.  13 


SAUNDERS'  QUESTION=COMPENDS.     See  page  16. 
SCUDDER'S  FRACTURES.    Third  Edition,  Revised. 

The  Treatment  of  Fractures.     By  Chas  L.  Scudder   M.  D.    Assistant  in 
Ar   ■  oi  ;r,H  Dnerative  Sureerv   Harvard  University  Medical  School.     Oc- 
taro'Ss^agSwXne'arly'eoo  original  illustrations.     Polished  Buckram, 
net;  Half  Morocco,  net. 

SENN'S  QEN1T0=UR1NARY  TUBERCULOSIS. 

Tuberculosis  of  the  Genito-Urinary  Organs,  Male  and  Female.     By  NiCH-  ^ 
OLAS  SENN    M.D.,   PH.D.,   LL.D.,    Professor  of  Surgery,  Rush  Medical 
CoUege    Chicago.     Handsome  octavo   volume  of  320   pages,   illustrated. 
Cloth,  fo.oo  net. 

SENN'S  PRACTICAL  SURGERY. 

Practical  Surgery.  By  NICHOLAS  SENN,  M.  D.,  PH  D.,  LL.D.,  Professor 
of  Sur-ery  Rush  Medical  College,  Chicago.  Handsome  octavo  volume 
of  iS  pages,  642  illustrations.  Cloth,  $6.00  net ;  Sheep  or  Half  Morocco, 
$7.00  net.     By  Subscription. 

SENN'S  SYLLABUS  OF  SURGERY. 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery   arranged  in  conformity 
with  "An  American  Text-Book  of  Surgery."     By  NICHOLAS  SENN    M.  D 
PH  D.,    LL.D.,    Professor   of  Surgery,  Rush    Medical   College,    Chicago. 
Cloth,  ^1.50  net. 

SENN'S  TUMORS.    Second  Edition,  Revised. 

Pathology  and  Surgical  Treatment  of  Tumors.  By  NICHOLAS  SENN  M.  D., 
Si  D  LL  D.,  Professor  of  Surgery,  Rush  Medical  College,  Chicago. 
Handsome  octavo  volume  of  718  pages  with  478  illustrations,  includ- 
ing 12  full-page  plates  in  colors.  Cloth,  $S.oo  net ;  Sheep  or  Half 
Morocco,  ^6.00  net. 

SOLLMANN'S  PHARMACOLOGY. 

A  Text-Book  of  Pharmacology.  By  TORALD  Sollmann,  M.  D.,  Assistant 
Professor  of  Pharmacology  and  Materia  Medica,  Western  Reserve  Univer- 
sity, Cleveland,  Ohio.  Royal  octavo  volume  of  894  pages,  fully  illustrated. 
Cloth,  #3.75  net. 

STARR'S  DIETS  FOR  INFANTS  AND  CHILDREN. 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.    By  Louis  Starr, 
M  D     Editor  of  "An  American  Text-Book  of  the  Diseases  of  Children. 
230  blanks  (pocket-book  size),   perforated   and   neatly   bound   in    flexible 
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STELWAGON'S  DISEASES  OF  THE  SKIN. 

Diseases  of  the  Skin.  By  Henry -W.  Stelwagon,  M.D.,  Clinical  Pro- 
fessor of  Dermatology,  Jefferson  Medical  College,  Philadelphia.  Royal 
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X4  MEDICAL  PUBLICATIONS 


STENGEL'S  PATHOLOGY.  Third  Edition,  Thoroughly  Revised. 

A  Text-Book  of  Pathology.  By  Alfred  Stengel.  M.  D.,  Professor  of 
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STENGEL  AND  WHITE  ON  THE  BLOOD. 

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C.Y.White,  Jr.,  M.D.,  Instructor  in  Chnical  Medicine,  University  of 
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OF  W.  B.  SAUNDERS  &=  CO.  15 


THORNTON'S  DOSE=BOOK  AND  PRESCRIPTI0N=WRIT1NQ. 
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VIERORDT'S    MEDICAL    DIAGNOSIS.     Fourth    Edition,  Re= 

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Medical  Diagnosis.  By  Dr.  Oswald  Vierordt,  Professor  of  Medicine, 
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series  of  articles  on  Regional  Bacteriology.  Cloth,  ^5.00  net ;  Sheep  or 
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WARWICK  AND  TUNSTALL'S  FIRST  AID  TO  THE  INJURED 
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Cantab.,  M.  R.  C.  S.,  Surgeon-Captain,  Volunteer  Medical  Staff  Corps, 
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Charles  G.  L.  Wolf,  M.  D.,  Instructor  in  Physiologic  Chemistry,  Cor- 
nell University  Medical  College.  i2mo  volume  of  204  pages,  47  illustra- 
tions.    Cloth,  $i.2Z  net. 


Saunders' 
Question=Compend    Series. 

Price,  Cloth,  $i.oo  net  per  copy,  except  when  otherwise  noted. 


'  Where  the  work  of  preparing  students'  manuals  is  to  end  we  cannot  say,  but  the  Saunders 
Series,  in  our  opinion,  bears  off  the  palm  at  present." — New  York  Medical  Record. 


1.  Essentials   of   Physiology.      By   Sidney   Budgett,   M.  D.    An  entirely  new 

work. 

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with  an  Appendix  and  a  chapter  on  Appendicitis. 

3.  Essentials  of  Anatomy.     By  Charles   B.   Nancrede,   M.  D.     Sixth   edition, 

thoroughly  revised  and  enlarged.  \ 

4.  Essentials  of  Medical  Chemistry,  Organic  and  Inorganic.   By  Lawrence 

Wolff,  M.  D.     Fifth  edition,  revised. 

5.  Essentials  of  Obstetrics.     By  W.  Easterly  Ashton,  M.  D.        Fifth    edition, 

revised  and  enlarged. 

6.  Essentials  of  Pathology  and  Morhid  Anatomy.    By  F.  j.  Kalteyer,  m.  d. 

In  preparation. 

7.  Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription- Writing. 

By  Henry  Morris,  M.  D.     Fifth  edition,  revised. 

8.  9.     Essentials  of  Practice   of  Medicine.     By  Henry  Morris,  M.  D.     An  Ap- 

pendix on  Urine  Examination.  By  Lawrence  Wolff,  M.  D.  Third  edition, 
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10.  Essentials    of    Gynecology.     By    Edwin   B.   Cragin,   M.  D.         Fifth     edit'or, 

revised. 

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Fourth  edition,  revised  and  enlarged. 

12.  Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal  Diseases.    By 

Edward  Martin,  M.  D.     Second  edition,  revised  and  enlarged. 

13.  Essentials  of  Legal  Medicine,  Toxicology,  and  Hygiene.    This  volume  is 

at  present  out  of  print. 

14.  Essentials  of  Diseasea  of  the  Eye.     By  Edward  Jackson,  M.  D.    Third 

edition,  revised  and  enlarged. 

15.  Essentials  of  Diseases  of  Children.     By  William  M.  Powell,  M.  D.    Third 

16.  Essentials  of  Examination  of  Urine.     By  Lawrence  Wolff,  M.  D.     Colored 

"  VoGEL  Scale."     (75  cents  net.) 

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Second  edition,  thoroughlj'  revised. 

18.  Essentials  of  Practice  of  Pharmacy.     By  Lucius  E.  Sayre.    Second  edition, 

revised  and  enlarged. 

19.  Essentials  of  Diseases  of  the  Nose  and  Throat.    By  E.  B.  Glbason,  m.  D 

Third  edition,  revised  and  enlarged. 

20.  Essentials  of  Bacteriology.     By  M.  v.  Ball,  M.  D.     Fourth  edition,  revised. 

21.  Essentials  of  Nervous  Diseases  and  Insanity.    By  John  c.  Shaw,  m.d. 

Third  edition,  revised. 

22.  Essentials  of  Medical  Physics.     By  Fred  J.  Brockway,  M.  D.     Second  edi- 

tion, revised. 

23.  Essentials  of  Medical  Electricity.     By  David  D.  Stewart,  M.  D.,  and  Ed- 

ward S.  Lawrance,  M.  D. 

24.  Essentials  of  Diseases  of  the  Ear.    By  E.  B.  Gleason,  M.  D.    Third  Edi- . 

tion,  revised  and  greatly  enlarged.  ' 

25.  Essentials   of   Histology.      By  Louis  Leroy,  M.  D.     Second  edition,  revised. 

With  95  original  illustrations. 


Pamphlet  containing  specimen  pages,  etc.,  sent  free  upon  application. 
16 


Saunders'  Medical  Hand=Atlases. 


volume:s  now  ready, 

atlas  and  epitome  of  internal  medicine  and 
clinical  diagnosis. 

By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited  by  AUGUSTUS  A.  ESHNER, 
M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  With  179 
colored  figures  on  68  plates,  64  text-iliustrations,  259  pages  of  te.xt.  Cloth, 
^3.00  net. 

ATLAS  OF  LEGAL  MEDICINE. 

By  Dr.  E.  R.  von  Hoffman,  of  Vienna.  Edited  by  Frederick  Peter- 
son, M.  D.,  Chief  of  Clinic,  Nervous  Department,  College  of  Physicians  and 
Surgeons,  New  York.  With  120  colored  figures  on  56  plates  and  193  beau- 
tiful half-tone  illustrations.     Cloth,  ^3.50  net. 

ATLAS  AND  EPITOME  OF  DISEASES  OF  THE  LARYNX. 

By  Dr.  L.  Grunwald,  of  Munich.  Edited  by  CHARLES  P.  Grayson, 
M.  D.,  Physician-in-Charge,  Throat  and  Nose  Department,  Hospital  of  the 
University  of  Pennsylvania.  With  107  colored  figures  on  44  plates,  25  text- 
illustrations,  and  103  pages  of  text.     Cloth,  ^^2.50  net. 

ATLAS  AND    EPITOME  OF  OPERATIVE   SURGERY.     Second 

Edition,  Thoroughly  Revised  and  Greatly  Enlarged. 

By  Dr.  O.  Zuckerkandu,  of  Vienna.  Edited,  with  additions,  by  J.  Chal- 
mers DaCosta,  M.  D.,  Professor  of  Principles  of  Surgery  and  of  Clinical 
Surgery,  Jefferson  Medical  College,  Philadelphia.  With  40  colored  plates, 
278  text-illustrations,  and  410  pages  of  text.     Cloth,  $3.50  net. 

ATLAS  AND  EPITOME  OF  SYPHILIS  AND  THE  VENEREAL 

DISEASES. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited,  with  additions,  by  L. 
Bolton  Bangs,  M.  D.,  Professor  of  Genito-Urinary  Surgery,  University 
and  Bellevue  Hospital  Medical  College,  New  York.  With  71  colored  plates, 
16  text-illustrations,  and  122  pages  of  text.     Cloth,  ^3.50  net. 

ATLAS  AND  EPITOME  OF  EXTERNAL  DIS.  OF  THE  EYE. 

By  Dr.  O.  Haab,  of  Zurich.  Edited  by  G.  E.  DE  SCHWEINITZ,  M.  D., 
Professor  of  Ophthalmology,  Jefferson  Medical  College,  Philadelphia.  With 
76  colored  illustrations  on  40  plates  and  228  pages  of  text.     Cloth,  ^3.00  net. 

ATLAS  AND  EPITOME  OF  SKIN  DISEASES. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  Henry  W.  Stel- 
WAGON.  M.  D.,  Clinical  Professor  of  Dermatology,  Jefferson  Medical  Col- 
lege, Philadelphia.  With  63  colored  plates,  39  half-tone  illustrations,  and 
200  pages  of  text.     Cloth,  fe.50  net. 

ATLAS  AND   EPITOME  OF  SPECIAL  PATHOLOGICAL  H1S= 
TO  LOGY. 

By  Dr.  H.  DOrck,  of  Munich.  Edited  by  LUDVIG  Hektoen,  M.  D., 
Professor  of  Pathology,  Rush  Medical  College,  Chicago.  In  Two  Parts. 
Part  I.,  including  Circulatory,  Respiratory,  and  Gastro-intestinal  Tract, 
120  colored  figures  on  62  plates,  158  pages  of  text.  Part  II.,  including 
Liver,  Urinary  Organs,  Sexual  Organs,  Nervous  System,  Skin,  Muscles, 
and  Bones.  123  colored  figures  on  60  plates,  192  pages  of  text.  Per 
volume :  Cloth,  53-°°  net. 

17 


Saunders'  Medical  Hand=Atlases. 

VOLUMES  JUST  ISSUED. 

ATLAS  AND   EPITOME  OF  DISEASES   CAUSED   BY    ACCI= 
DENTS. 

By  Dr.  Ed.  Golebiewski,  of  Berlin.  Edited,  with  additions,  by  Pearce 
Bailey,  M.  D.,  Attending  Physician  to  the  Department  of  Corrections  and 
to  the  Almshouse  and  Incurable  Hospitals,  New  York.  With  40  colored 
plates,  143  text-illustrations,  and  600  pages  of  te.xt.     Cloth,  34.00  net. 

ATLAS  AND  EPITOME  OF  GYNECOLOGY. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Second  Revised  German 
Edition.  Edited,  with  addiuons,  by  Richard  C.  Norris,  A.M.,  M.  D., 
Gynecologist  to  the  Methodist  Episcopal  and  the  Philadelphia  Hospitals; 
Surgeon-in-Charge  of  Preston  Retreat,  Philadelphia.  With  90  colored 
plates,  65  te.xt-illustrations,  and  308  pages  of  text.     Cloth,  ^3.50  net. 

ATLAS  AND  EPITOME  OF  THE  NERVOUS  SYSTEM  AND  ITS 
DISEASES. 

By  Professor  Dr.  Chr.  J.akob,  of  Erlangen.  From  the  Second  Revised 
and  Enlarged  German  Edition.  Edited,  with  additions,  by  EDWARD  D. 
Fisher,  M.  D.,  Professor  of  Diseases  of  the  Nervous  System,  University 
and  Bellevue   Hospital  Medical  College,  N.  Y.     With  83  plates;   copious 

text.     33-50  net. 

ATLAS   AND   EPITOME   OF   LABOR   AND   OPERATIVE    OB= 
STETRICS. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Fifth  Revised  and  En- 
larged German  Edition.  Edited,  with  additions,  by  J.  CLIFTON  EDGAR, 
M.  D.,  Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University 
Medical  School.     With  126  colored  illustrations.     S2.00  net. 

ATLAS  AND  EPITOME  OF  OBSTETRICAL  DIAGNOSIS  AND 
TREATMENT. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Second  Revised  and 
Enlarged  German  Edition.  Edited,  with  additions,  by  J.  CLIFTON  EDGAR, 
M.  D.,  Professor  of  Obstetrics  and  CHnical  Midwifery',  Cornell  University 
Medical  School.  72  colored  plates,  numerous  text-illustrations,  and  copious 
text.     $3.00  net. 

ATLAS  AND  EPITOME  OF  OPHTHALMOSCOPY   AND   OPH= 
THALMOSCOPIC  DIAGNOSIS. 

By  Dr.  O.  H.A.\B,  of  Zurich.  Front  the  Third  Revised  and  Enlarged  Ger- 
man Edition.  Edited,  with  additions,  by  G.  E.  DE  SCHWEIMTZ,  M.  D., 
Professor  of  Ophthalmology,  Jefferson  Medical  College,  Philadelphia. 
With  152  colored  figures  and  82  pages  of  text.     Cloth,  $3.00  net. 

ATLAS  AND  EPITOME  OF  BACTERIOLOGY. 

Including  a  Hand-Book  of  Special  Bacteriologic  Diagnosis.  By  PROF. 
Dr.  K.  B.  Lehmann  and  Dr.  R.  O.  Neu.MANX,  of  Wiirzburg.  From  the 
Second  Revised  German  Edition.  Edited,  with  additions,  by  GEORGE  H. 
Weaver,  M.  D.,  Assistant  Professor  of  Pathology  and  Bacteriology,  Rush 
Medical  College.  In  Two  Parts.  Part  I.,  consisting  of  632  colored  figures 
on  69  plates.  Part  II.,  consisting  of  511  pages  of  text,  illustrated.  Per 
Part :   Cloth,  §2.50  net. 

18 


Saunders'  Medical  Hand=Atlases. 

VOLUMES   JUST    ISSUED. 

ATLAS  AND  EPITOME  OF  OTOLOGY. 

By  Dr.  Gt  STAV  Bruhl,  of  Berlin,  with  the  collaboration  of  Prof.  Dr.  A. 
PoLlTZER,  of  Vienna.  Edited,  %\ith  additions,  by  S.  M.\cCuEN  SMITH, 
M.  D.,  Clinical  Professor  of  Otology,  Jefferson  Medical  College,  Philadel- 
phia. 244  colored  figures  on  39  plates,  99  text-cuts,  and  292  pages  of  text. 
Cloth,  $3.00  net. 

ATLAS  AND  EPITOME  OF  ABDOMINAL  HERNIAS. 

By  PRIV.A.TDOCENT  Dr.  Geokg  Sl  ltax,  of  Gottingen.  Edited,  with 
additions,  by  WiLLlAM  B.  CoLEV,  Clinical  Lecturer  on  Surgerv,  Columbia 
University  (College  of  Physicians  and  Surgeons),  New  York  ;  Surgeon  to 
the  General  Memorial  Hospital,  New  York.  With  43  colored  figures  on 
36  plates,  100  text-cuts,  and  about  275  pages  of  text.     Cloth,  30.00  net. 

ATLAS  AND  EPITOME  OF   FRACTURES   AND   LUXATIONS. 

By  Prof.  Dr.  H.  Helferich.  of  Greifswald.  Edited,  with  additions,  by 
Joseph  C.  Bloodgood,  Associate  in  Surgery,  Johns  Hopkins  University, 
Baltimore.  With  215  colored  figures  on  72  plates,  144  te.xt-cuts,  42  skia- 
graphs, and  over  300  pages  of  text.     Cloth,  So. 00  net. 

ATLAS  AND  EPITOME  OF  DISEASES  OF  MOUTH,  THROAT, 
AND  NOSE. 

By  Dr.  L.  Grl'NWALD,  of  Munich.  From  the  Second  Revised  and  Enlarged 
German  Edition.  Edited,  with  additions,  by  jAMES  E.  Xewcomb,  M.  D., 
Clinical   Instructor  in   Laryngology,  Cornell    University   Medical  School. 

With  42  colored  figures.  39  text-cuis.  and  225  pages  of  text. 

ATLAS  AND  EPITOME  OF  NORMAL  HISTOLOGY. 

By  Priv.atdocent  Dr.  J-  Sobott.\,  of  Wiirzburg.  Edited,  with  additions, 
by  G.  C-ARL  Huber,  M.  D.,  Junior  Professor  of  Anatomy  and  Director  of 
the  Histological  Laboratory,  University  of  Michigan.  With  80  colored 
figures  and  68  text-cuts  from  the  original  of  W.  Freytag.  and  275  pages 
of  text. 

ATLAS  AND  EPITOME   OF  OPERATIVE   GYNECOLOGY. 

By  Dr.  Osk.\r  Sch.a.effer,  Privatdocent  in  the  University  of  Heidelberg. 
With  42  colored  figures  and  21  text-cuts  from  the  original  of  A.  Schmitson, 

and  125  pages  of  text. 

SAUNDERS*  MEDICAL  HAND-ATLASES. 

Three  years  ago  Mr.  Saunders  contracted  for  100,000  copies  of  the  twenty- 
six  volumes  that  are  to  compose  this  series  of  books.  Of  these  twenti,'-six  vol- 
umes only  eighteen  have  appeared,  and  yet  over 

80.000   Copies 

have  already  been  imported.  Basing  the  sales  of  future  numbers  on  those 
already  issued,  the  prospects  are  that  the  ultimate  sale  of  these  volumes  will 
more  than  double  the  figures  originally  set. 


ADDITIONAL  VOLUMES  IN  PREP.4RATI0N. 

19 


Nothnagel's  Encyclopedia 

OF 

PRACTICAL    MEDICINE. 

AMERICAN  EDITION. 
Edited  by  ALFRED  STENGEL,  M.D., 

Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania;  Visiting 
Phj-sician  to  the  Pennsylvania  Hospital. 

¥T  is  universally  acknowledged  that  the  Germans  lead  the  world  in  Internal  Medicine: 
'  and  of  all  the  German  works  on  this  subject,  Nothnagel's  "  Specielle  Patholog-ie  und 
Therapie  "  is  conceded  bj-  scholars  to  be  without  question  the  best  System  of  Medicine 
in  existence.  So  necessary-  is  this  book  in  the  study  of  Internal  Medicine  that  it  comes 
largely  to  this  country  in  the  original  German.  In  view  of  these  facts,  Messrs.  \V.  B. 
Saunders  &  Company  have  arranged  with  the  publishers  to  issue  at  once  an  authorized 
American  edition  of  this  great  encj-clopedia  of  medicine. 

For  the  present  a  set  of  ten  volumes,  representing  the  most  practical  part  of  this 
excellent  encyclopedia,  and  selected  with  especial  thought  of  the  needs  of  the  practical 
physician,  will  be  published.  These  volumes  will  contain  the  real  essence  of  the  entire 
work,  and  the  purchaser  will  therefore  obtain  at  less  than  half  the  cost  the  cream  of  the  origi- 
nal.    Later  the  special  and  more  strictly  scientific  volumes  vnll  be  offered  fi-om  time  to  time. 

The  work  will  be  translated  by  men  possessing  thorough  knowledge  of  both  English  and 
German,  and  each  volume  will  be  edited  by  a  prominent  specialist  on  the  subject  to 
which  it  is  devoted.  It  will  thus  be  brought  thoroughly  up  to  date,  and  the  American  edition 
will  be  more  than  a  mere  translation  of  the  German  ;  for,  in  addition  to  the  matter  contained 
in  the  original,  it  will  represent  the  very  latest  views  of  the  leading  American  and 
English  specialists  in  the  various  departments  of  Internal  Medicine.  The  whole  System 
will  be  under  the  editorial  supervision  of  Dr.  Alfred  Stengel,  who  will  select  the  subject; 
for  the  American  edition,  and  will  choose  the  editors  of  the  different  volumes. 

Unlike  most  encj'clopedias,  the  publication  of  this  work  wrill  not  be  extended  over  a 
number  of  years,  but  five  or  six  volumes  will  be  issued  dimng  the  coming  year,  and  the 
remainder  of  the  series  at  the  same  rate.  IMoreover,  each  volume  will  be  revised  to  the 
date  of  its  publication  by  the  eminent  editor.  This  will  ob^-iate  the  objection  that  has 
heretofore  existed  to  systems  published  in  a  number  of  volumes,  since  the  subscriber  will 
receive  the  completed  work  while  the  earlier  volumes  are  still  fresh. 

The  usual  method  of  publishers,  when  issuing  a  work  of  this  kind,  has  been  to  compel 
physicians  to  take  the  entire  System.  This  seems  to  us  in  many  cases  to  be  undesirable. 
Therefore,  in  purchasing  this  encyclopedia,  physicians  will  be  given  the  opportunity  of 
subscribing  for  the  entire  System  at  one  time;  but  any  single  volume  or  any  number  of 
volumes  may  be  obtained  by  those  who  do  not  desire  the  complete  series.  This  latter 
method,  while  not  so  profitable  to  the  publishers,  offers  to  the  purchaser  many  advan- 
tages which  will  be  appreciated  b}-  those  who  do  not  care  to  subscribe  for  the  entire  work 
at  one  time. 

This  American  edition  of  Xothnagel's  Encyclopedia  will,  without  question,  form  the 
greatest  System  of  Medicine  ever  produced,  and  the  publishers  are  confident  that  it 
will  meet  with  general  favor  in  the  medical  profession. 

20 


NOTHNAGEL^S  ENCYCLOPEDIA. 

AMERICAN  EDITION. 

VOLUMES  JUST  ISSUED  AND  IN  PRESS. 

TYPHOID  AND  TYPHUS  FEVERS.     By  Dr.  H.  Curschmann,  of  Leipsic. 

Editor, 'W'illiam  Osier,   M.D.,   F.R.C.P.,   Professor  of  the  Principles  and  Practice 

of  Medicine  in  Jolins  Hopkins  University,  Baltimore.  Handsome  octavo,  646  pages, 
72  valuable  text  illustrations,  and  two  lithographic  plates.  Cloth,  $5.00  net ;  Half 
Morocco,  ;j56.oo  net.    Just  Ready. 

VARIOLA  (including  VACCINATION).  By  Dr.  H.  Immermann,  of  Basle. 
VARICELLA.  By  Dr.  Th.  von  Jurgensen,  of  Tubingen.  CHOLERA 
ASIATICA  and  CHOLERA  NOSTRAS.  By  Dr.  C.  Liebekmeister,  of 
Tubingen.  ERYSIPELAS  and  ERYSIPELOID.  By  Dr.  H.  Lenhartz,  of 
Hamburg.  PERTUSSIS  and  HAY-FEVER.  By  Dr.  G.  Sticker,  of  Giessen. 
Editor,  Sir  J.  W.  Moore,  B.A.,  M.D.,  F.R.C.P.I.,  Professor  of  the  Practice  of 
Medicine,  Royal  College  of  Surgeons,  Ireland.  Handsome  octavo  of  682  pages,  illus- 
trated.    Cloth,  ^5.00  net  ;  Half  Morocco,  $6.00  net.    Just  Ready. 

DIPHTHERIA.     By  the  editor.    Measles,  Scarlet  Fever,  Rotheln.     By  Dr.  Th,  von 

Jurgensen,  of  Tiibingen. 

Editor,  William  P.  Northrop,  M.D.,  Professor  of  Pediatrics,  University  and  Belle- 
vue  Medical  College,  N.  Y.  Handsome  octavo,  672  pages,  illustrated,  including  24 
full-page  plates,  3  in  colors.     Cloth,  fc.oo  net ;   Half  Morocco,  ^6.00  net.    Just  Ready. 

DfSEASES  OF  THE  BRONCHL  By  Dr.  F.  A.  Hoffmann,  of  Leipsic.  DIS- 
EASES OF  THE  PLEURA.  By  Dr.  O.  Roseneach,  of  Berlin.  PNEU- 
MONIA.    By  Dr.  E.  Aufrecht,  of   Magdeburg. 

Editor,  John  H.  Musser,  M.  D.,  Professor  of  Clinical  Medicine,  University  of  Penn- 
sylvania. Handsome  octavo,  700  pages,  7  full-page  lithographs  in  colors.  Cloth,  )^5.oo 
net ;  Half  Morocco,  g6.oo  net.    Just  Ready. 

DISEASES  OF  THE  LIVER.  By  Dks.  H.  Quincke  and  G.  Hoppe-Skyler.  of 
Kiel.  DISEASES  OF  THE  PANCREAS.  By  Dr.  L.  Oser.  of  Vienna.  DIS- 
EASES OF  THE  SUPRARENALS.  By  Dk.  E.  Neusser,  of  Vienna. 
Editors,  Frederick  A.  Packard,  M.  D.,  Physician  to  the  Penna.  and  the  Children's 
Hospitals,  Phila. ;  and  Reginald  H.  FitZ,  A.  M,,  M.  D.,  Hersey  Prof,  of  the  Theory 
and  Practice  of  Physic,  Harvard  Univ.  Handsome  octavo,  700  pages,  illustrated. 
Cloth,  jSs-oo  'let ;    Half  Morocco,  j^6.oo  net.      Just  Ready. 

INFLUENZA  AND  DENGUE.  By  Dr.  O.  Leichtenstern,  of  Cologne.  MALA- 
RIAL DISEASES.     By  Dr.  J.  Mannaberg,  of  Vienna. 

Editor,  Ronald  Ross,  F.R.C.S.,  Eng.,  D.P.H.,  F.R.S.,  Major,  Indian  Medical 
Service,  retired ;  Walter  Myers  Lecturer,  Liverpool  School  of  Tropical  Medicine. 
Handsome  octavo,  700  pages,  7  full-page  lithographs  in  colors. 

ANEMIA,  LEUKEMIA,   PSEUDOLEUKEMIA,  HEMOGLOBINEMIA.    By 

Dr.  p.  Ehrlich,  of  Frankfort-on-the-Main,  Dr.  A.  Lazarus,  of  Charlottenburg,  and 
Dr.  Felix  Pinkus,  of  Berlin.  CHLOROSIS.  By  Dr.  K.  von  Noorden,  of 
Frankfort-on-the-Main. 

Editor,  Alfred  Stengel,  M.D.,  Professor  of  Clinical  Medicine,  University  of  Pennsyl- 
vania.    Handsome  octavo,  750  pages,  5  full-page  lithographs  in  colors. 

TUBERCULOSIS  AND  ACUTE  GENERAL  MILIARY  TUBERCULOSIS. 

By  Dr.  G.  Cornet,  of  Berlin. 

Editor  to  be  announced  later.     Handsome  octavo,  700  pages. 

DISEASES  OF  THE  STOMACH.     By  Dr.  F.  Riegel,  of  Giessen. 

Editor,  Charles  G.  Stockton,  M.D.,  Professor  of  Medicine,  University  of  Buffalo. 
Handsome  octavo,  800  pages,  with  29  text-cuts  and  6  full-page  plates. 

DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.  By  Dr.  Hermann 
Nothnagel,  of  Vienna. 

Editor.  Humphry  D.  Rolleston,  M.D.,  F.R.C.P.,  Physician  to  and  Lecturer  on 
Pathology  at  St.  George's  Hospital,  London.  Handsome  octavo,  800  pages,  finely 
illustrated. 


CLASSIFIED    LIST 

OF    THE 

MEDICAL    PUBLICATIONS 


W.  B  Saunders  &  Company. 


ANATOMY,  EMBRYOLOGY,  HIS- 
TOLOGY. 

Bbhm,  Davidoff,  and  Huber — A  Text- 
Book  of  Histology, 4 

Clarkson — A  Text-Book  of  Histology,  .  s 

Haynes — A  Manual  of  Anatomy,    ...  8 

Heisler — A  Text-Book  of  Embryology,  8 

Leroy — Essentials  of  Histology,  .    .    .    .  i6 
McClellan — Anatomy    in    Relation     to 

Art ;  Regional  Anatomy, lo 

Nancrede — Essentials  of  Anatomy,    .    .  i5 
Nancrede — Essentials  of  Anatomy  and 

Manual  of  Practical  Dissection,    .    .    .  ii 

Sabotta — Atlas  of  Normal  Histology,    .  19 

BACTERIOLOGY. 

Ball — Essentials  of  Bacteriology,     ...  16 

Eyre — Bacteriologic  Technique,   ....  7 

Frothingham — Laboratory  Guide,     .    .  7 

Gorham — Laboratory  Bacteriology,  .    .  7 
Lehmann    and    Neumann — Atlas    of 

Bacteriology, 18 

Levy  and  Klemperer's  ClinicaJ  Bacte- 
riology,    10 

Mallory    and     Wright — Pathological 

Technique, 10 

McFarland — Pathogenic  Bacteria,     .    .  11 

CHARTS,  DIET-LISTS,  ETC. 

Griffith— Infant's  Weight  Chart,  ....  8 

Keen — Operation  Blank, 9 

Laine — Temperature  Chart, 10 

Meigs — Feeding  in  Early  Infancy,  ...  11 

Starr — Diets  for  Infants  and  Children,  .  13 

Thomas — Diet-Lists, 14 

CHEMISTRY  AND  PHYSICS. 

Brockway — Ess.  of  Medical  Physics,    .  16 

Jelliffe  and  Diekman — Chemistry,     .    .  9 

■Wolf — Examination  of  Urine 15 

AA^olff— Essentials  of  Medical  Chemistry,  16 

CHILDREN. 

American  Text-Book  Dis.  Children,    .  i 

Griffith— Care  of  the  Baby 8 

Griffith— Infant's  Weight  Chart,      ...  8 

Meigs — Feeding  in  Early  Infancy,  ...  11 

Powell — Essentials  of  Dis.  of  Children,  16 

Starr — Diets  for  Irfants  and  Children,  .  13 

DIAGNOSIS. 

Cohen  and  Eshner — Essentials  of  Diag- 
nosis,     i6 

Corwin — Physical  Diagnosis, 5 

Vierordt — Medical  Diagnosis 15 

DICTIONARIES. 

The    American    Illustrated    Medical 

Dictionary, 3 

The  American  Pocket  Medical  Dic- 
tionary,    3 

Morton — Nurses'  Dictionary, 11 


EYE,  EAR,  NOSE,  AND  THROAT. 

An  American  Text-Book  of  Diseases 

of  the  Eye,  Ear,  Nose,  and  Throat,     .  i 
Briihl  and  Politzer — Atlas  of  Otology,  19 
De  Schweinitz — Diseases  of  the  Eye,  .  6 
Friedrich  and  Curtis— Rhinology,  Lar- 
yngology, and  Otology, 7 

Gleason — Essentials  of  the  Ear,  ....  16 

Gleason — Essentials  of  Nose  and  Throat,  16 

Gradle — Nose,  Pharynx,  and  Ear,  ...  7 
Griinwald — Atlas    of   Mouth,    Throat, 

and  Nose, 19 

Griinwald — Atlas  of  Dis.  of  Larynx,    .  17 

Haab — Atlas  of  External  Dis.  of  Eye,  .  17 

Haab — Atlas  of  Ophthalmology,  ....  18 

Jackson — Manual  of  Diseases  of  the  Eye,  9 

Jackson — Essentials  Diseases  of  Eye,    .  16 

Kyle — Diseases  of  the  Nose  and  Throat,  9 

GENITO-URINARY. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 2 

Hyde  and  Montgomery — Syphilis  and 
the  Venereal  Diseases, 8 

Martin — Essentials  of  Minor  Surgery, 
Bandaging,  and  Venereal  Diseases,     .    16 

Mracek — Atlas  of  Syphilis  and  the  Ven- 
ereal Diseases, 17 

Saundby — Renal  and  Urinary  Diseases,    12 

Senn — Genito-Urinary  Tuberculosis,  .    .    13 

Vecki — Sexual  Impotence, 15 

GYNECOLOGY. 

American  Text-Book  of  Gynecology 
Cragin — Essentials  of  Gynecology,  .  .  16 
Garrigues — Diseases  of  Women,  .  .  7 
Long — Syllabus  of  Gynecology,  . 
Penrose — Diseases  of  Women,    . 

Schaeffer — Atlas  of  Gynecology,    ... 

Schaeffer — Atlas  of  Oper.  Gynecolog-j%    19 

HYGIENE. 
Abbott — Hygiene  of  Transmissible  Dis- 
eases,   4 

Bergey — Principles  of  Hygiene,  ....      4 
Pyle — Personal  Hygiene, 12 

MATERIA      MEDICA,     PHARMA- 
COLOGY, and  THERAPEUTICS. 
An  American   Text-Book  of  Applied 

Therapeutics i 

Butler — Text-Book  of  Materia  Medica, 

Therapeutics,  and  Pharmacology,  .  .  5 
Morris — Ess.  of  M.M.  and  Therapeutics,  16 
Saunders'  Pocket  Medical  Formulary,  12 
Sayre — Essentials  of  Pharmacy,  ....  16 
SoUmann — Text-Book  of  Pharmacology,  13 
Stevens— Modern  Therapeutics,  ....  14 
Stoney — Materia  Medica  for  Nurses,  .  .  14 
Thornton — Prescription-Writing,    ...    15 


MEDIC  A  L  PUBLICA  TIONS. 


23 


MEDICAL  JURISPRUDENCE  AND 
TOXICOLOGY. 

Chapman — Medical  Jurisprudence  and 
Toxicolog^y, 5 

Crothers — Morphinism, 6 

Golebiew^ski — Atlas  of  Diseases  Caused 
by  Accidents, 18 

Hofmann — Atlas  of  Legal  Medicine,  .    .    17 

NERVOUS  AND  MENTAL   DIS- 
EASES. ETC. 

Brower — Manual  of  Insanity, 5 

Chapin — Compendium  of  Insanity,     .    .      5 
Church   and  Peterson — Nervous    and 

Mental   Diseases, 5 

Jakob — Atlas  of  Nervous  System,   ...    18 
Shaw — Essentials  of  Nervous  Diseases 

and  Insanity, 16 

NURSING. 
Davis — Obstetric  and  Gynecologic  Nurs- 
ing,    6 

Griffith— The  Care  of  the  Baby,  ....  8 

Meigs — Feeding  in  Early  Infancy,  ...  11 

Morten — Nurses'  Dictionary, 11 

Stoney — Materia  Medica  for  Nurses,      .  14 

Stoney — Practical  Points  in  Nursing,    .  14 

Stoney — Surgical  Technique  for  Nurses,  14 

'Watson — Handbook  for  Nurses,     ...  15 

OBSTETRICS. 

An  American  Text-Book  of  Obstetrics,      2 
Ashton — Essentials  of  Obstetrics,   ...    16 
Boisliniere — Obstetric  Accidents, 
Dorland — Modern  Obstetrics,   .    . 
Hirst — Text-Book  of  Obstetrics,  . 
Norris — Syllabus  of  Obstetrics,    . 
Schaeffer — Atlas  Labor  and  Oper.  Obs 
Schaeffer — Atlas   of   Obstetrical    Diag- 
nosis and  Treatment, i 


PATHOLOGY. 

An  American  Text-Book  of  Pathology,  2 

Durck — Atlas  of  Pathologic   Histology,  17 

Kalteyer — Essentials  of  Pathology,,  .  .  16 
Mallory     and     'Wright — Pathological 

Technique, 10 

Senn — Pathology  and    Surgical    Treat- 
ment of  Tumors, 13 

Stengel — Text-Book  of  Pathology,     .    .  14 

Stengel  and  'White — Blood, 14 

Warren— Surgical  Pathology, 15 

PHYSIOLOGY. 

American  Text-Book  of  Physiology,  .  2 

Raymond— Text-Book  of  Physiology,  .  12 

Stewart— Manual  of  Physiology,    ...  14 

PRACTICE  OF  MEDICINE. 

American  Text-Book  of  Theoi  v  &  Prac.  3 
An  American  Year-Book  of  Medicine 

and  Surgery, 3 

Anders — Practice  of  Medicine, 4 

Eichhorst— Practice  of  Medicine,  ...  6 
Lockwood— Practice  of  Medicine,  ...  10 
Morris — Ess.  of  Practice  of  Medicine,  .  16 
Nothnagel's  Encyclopedia,  ....  20,  21 
Salinger  &  Kalteyer— Mod.  Medicine,  12 
Stevens— Practice  of  Medicine,   ....    14 


SKIN  AND  VENEREAL. 
An  American    Text-Book   of   Genito- 
urinary and  Sk'.n  Diseases. 2 

Hyde  and  Montgomery— Syphilis  and 

the  Venereal  Diseases, .8 

Martin — Essentials   of   Minor   Surgery, 

Bandaging,  and  'Venereal  Diseases,  .  .  16 
Mracek— Atlas  of  Diseases  of  the  Skin,  17 
Stelwagon — Diseases  of  the  Skin,  ...  13 
Stelwagon  — Ess.  of  Diseases  of  Skin,  .    16 

SURGERY. 

An  American  Text-Book  of  Surgery,  .  2 
An  American  Year-Book  of  Medicine 

and  Surgery,      3 

Beck — Fractures, 4 

Beck — Manual  of  Surgical  Asepsis,     .    .  4 

DaCosta — Manual  of  Surgery,  ....  6 
Grant — Surgical  Disease  of  Face,  Mouth, 

and  Jaws, 8 

Helferich— Atlas  of  Fractures,     ....  19 

International  Text-Book  of  Surgery,  .  9 

Keen — Operation  Blank, 9 

Keen — The  Surgical  Complications  and 

Sequels  of  Typhoid  Fever, 9 

Macdonald — Surgical     Diagnosis     and 

Treatment, 10 

Martin — Essentials   of  Minor   Surgery, 

Bandaging,  and  'Venereal  Diseases,  .    .  16 

Martin — Essentials  of  Surgery,     ....  16 

Moore — Orthopedic  Surgery, n 

Nancrede — Principles  of  Surgery,      .    .  11 

Pye — Bandaging  and  Surgical  Dressing,  12 

Scudder — 'I  reatment  of  Fractures,  ...  13 

Senn — Genito-Urinary  Tuberculosis,  .    .  13 

Senn — Practical  Surgery, 13 

Senn — Syllabus  of  Surgery, 13 

Senn — Pathology   and    Surgical   Treat- 
ment of  Tumors, 13 

Sultan — Atlas  of  Abdominal  Hernias,     .  19 
■Warren — Surgical  Pathology  and  Ther- 
apeutics,       15 

Zuckerkandl — Atlas  of  Operative  Sur- 
gery,       17 

URINE  AND  URINARY  DISEASES. 

Ogden — Clinical  Examination  of  Urine,  11 
Saundby — Renal  and  Urinary  Diseases,  12 
■Wolf — Handbook  of  Urine  Examination,  15 
'Wolff — Ess.  of  E.xamination  of  Urine,   .    16 

MISCELLANEOUS. 
Abbott — Hygiene  of  Transmissible  Dis- 
eases,    4 

Bastin — Laboratory  Exercises  in  Botany,   4 
Galbraith — The    Four   Epochs  of  Wo- 
man's Life, 7 

Golebiewski — Atlas  of  Diseases  Caused 

by  Accidents, 18 

Gould  and  Pyle — Anomalies  and  Curi- 
osities of  Medicine, 7 

Grafstrom — Massage, 8 

Keating — Life  Insurance, 9 

Pyle — .-\  Manual  of  Personal  Hygiene,  .  12 

Robson  &  Moynihan — DIs.  of  Pancreas,  12 
Saunders'  Medical  Hand-Atlases,  17,  18, 19 

Saunders'  Pocket  Medical  Formulary,  .  12 

Saunders'  Question-Compends,  ....  16 
Stewart  and  Lawrance — Essentials  of 

Medical  Electricity 16 

'Warwick  and  Tunstall — First  Aid,  .   .  15 


^6,^. 


C^ 


COLUMBIA  UNIVERSITY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 


DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

C?S(63B)M50 

RC46  St4 

1900 
Stevens 


